A treatise on hysteria and epilepsy, with some concluding observations on epileptic insomnia

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A TREATISE ON

HYSTERIA AND EPILEPSY,

WITH

SOME CONCLUDING OBSERVATIONS ON
EPILEPTIC INSOMNIA,

J. LEONARD CORNING, M. A., M. D.,

ConsuHant in Nervous Diseases to St. Francis Hospital ; formerly one
of the Resident Physicians to the Hudson River State Hospital for
the Insane ; Fellow of the New York Academy of Medicine :
Member of the New York Neurological Society, of the Amer-
ican Neurological Association, of the Medical Society of
the County of New York of the Physicians'' Mutiial
Aid Association, of the Medical Society of
the State of New York
Author of "^ Treatise on Headache and Neuralgia,'' '^ Brain Rest,
being a DLsquisition on the Curative Properties of Prolonged
Sleep," ' Local Anaesthesia," "'Brain Exhaustion,
with Some Preliminary Considerations on
Cerebral Dynamics," ''Carotid
Compression" etc.

GEORGE S. DAVIS,

DETKOIT, UICH.

Copyrighted by

GEORGE S. DAVIS.

i88S.

TO THE MEMORY OF MY MATERNAL GRANDFATHER,

FREDERICK DEMING,

THESE PAGES ARE INSCRIBED AS A SLIGHT TOKEN OF

AFFECTION AND ADMIRATION FOR HIS

NOBLE QUALITIES OF HEART

AND MIND.

NOTE.

One year ago I published a series of papers on " Epi-
lepsy" and " Hysteria," which articles appeared in the "New-
York Medical Journal " and " Gaillard's Medical Journal."

The present publication is an amplification of those studies,
which, as they now appear, possess, to all intents and pur-
poses, the qualities of a systematic treatise.

26 West 47th Street, )
New York, July 30th, 1888. )"

TABLE OF CONTENTS.

PART

HYSTERIA.
CHAPTER. PAGE.

I. Introductory Note — Definition i

II. Symptomatology — Psychical Manifestations 4

III. Sensory Disorders — Hyperaesthesia 25

IV. Sensory Disorders Continued — Anaesthesia 37

V. Motor Disorders — Spasms — Paralysis 41

VI. Vaso motor Disorders — The Hysterical Cough. ... 49

VII. The Hysterical Paroxysm 57

VIII. Hysteria in Children — Hysteria in Men 62

IX. Causation — Pathology — Diagnosis 68

X. Prognosis — Treatment 74

PART II.

EPILEPSY.
CHAPTER. PAGE.

I. Classification — Symptomatology-Symptoms which
Immediately Precede the Attack — Aurae Epi-

lepticse 83

II. The Manifestations of the Epileptic Paroxysm —

Grand Mai go

III. The Manifestations of the Epileptic Paroxysm

Continued — Petit Mai — Seizurers Character-
ized by Loss of Consciousnes and Local
Spasms 05

IV. Masked Epilepsy gg

VIII.

PART II— EPILEPSY— Continued.

CHAPTER, Page.

V. "Thalamic" Epilepsy — Jacksonian Epilepsy —

Sensory Epilepsy 103

^ VI. Causation 109

— -VII. Experimental Researches 117

VIII. Experimental Researches Continued 123

IX. Patho-anatomical Findings 139

X. The Mechanism of the Epileptic Seizure 142

XI. Concerning the Nature of the Irritation — Theories

of Nothnagel, Todd and Hughlings Jackson. . 152

XII. Prognosis — Treatment 157

XIII. Treatment Concluded — Epileptic Insomnia 163

Index , 171

HYSTERIA.

CHAPTER I.

INTRODUCTORY NOTE— DEFINITION.

So heterogeneous and multitudinous are the symp-
toms of the disease known as hysteria that an exact
description of the affection is exceedingly difficult, and
an adequate definition little short of impossible.

We can be certain, however, that a large propor-
tion of the manifestations of the affection are directly
attributable to a functional derangement of the brain
and spinal cord, while not a few of the phenomena
are probably traceable to a morbid condition of the
sympathetic and peripheral nervous system.

It is impossible, moreover, to regard hysterical
phenomena as the result of other than purely func-
tional disturbances of the nervous system, since patho-
logical anatomy has failed to afford other than ' nega-
tive data. Nor is it probable that much enlighten-
ment as to the ultimate morphology of the disease is
to be anticipated from purely patho-anatomical sources
On the contrary, if we are ever to be informed as to
the nature of the occult pathology involved, it is un-
doubtedly to a future pathological chemistry that we

are to look for such knowledge. When, too, the pres-
ent incompleteness of physiological chemistry is borne
in mind, there is evidently no immediate prospect of
enlightenment from that source, were our metaphysi-
cal endeavors ever so great. It cannot, therefore, be
said that the probabilities of early enlightenment upon
the subtle pathological changes which lie at the root
of hysterical phenomena are considerable.

Whatever the ultimate nature of these changes
may be, we may nevertheless, rest assured that they
must be wide-spread in character, since only on the
basis of such an assumption is it possible to account
for the heterogeneous array of symptoms.

For the present, then, hysteria may be regarded
as a general neurosis of the nervous system, character-
ized by psychical, motor, sensory, secretory, vaso-
motor and reflex derangements. The justification for
including symptoms of so heterogeneous a nature un-
der one common designation has been questioned.
But, on the other hand, it has been urged that all
these symptoms, though not always, are frequently
associated in one and the same individual, so that the
assumption that they are all attributable to one gener-
al cause seems in a measure justifiable.

Be the merits in the case what they may, we shall,
at all events, adhere to current usage, if for no other
reason than to avoid uncertain and profitless dis-
cussion.

Dismissing this portion of the subject, we will

— 3 —
content ourselves with but one more observation, be-
fore proceeding to give a comprehensive description
of the affection. Owing to the circumstance that
hysteria is found to prevail to a greater extent among
women than men, and also to the fact that changes in
the condition of the female genital organs exert an
undoubted influence upon the development of hysteri-
calphenomena, it has been assumed that hysteria is an
affection exclusively confined to females. Moreover,
the same line of reasoning has led to the assumption
that hysteria is invariably the result of a diseased con-
dition of the genital organs.

The integrity of the first portion of this proposi-
tion simply depends upon the breadth of significance
which we give to the term hysteria. Most certainly a
lachrymose condition, accompanied by laughter and
choking, is found in men, as I have already had oc-
casion to show in former communications.* But
whether the more serious manifestations of the affec-
tion are found in the male sex has been questioned.

On the other hand, the second portion of the
proposition — that which assumes that hysteria is in-
variably the result of uterine or ovarian disease — may
be dismissed without further comment as manifestly
opposed to a vast sum of clinical evidence.

* Brain Exhaustion. By J. Leonard Corning, M. D.,
New York, D. Appleton & Co., 1884. p. 116, et seq.

CHAPTER II.

SYMPTOMATOLOGY— PSYCHICAL MANIFESTA-
TIONS.

Symptoms. — The disease usually develops gradu-
ally, though in certain cases there is apparently a
sudden exacerbation of symptoms, doubtless attrib-
utable to the fact that the prodromata had been
overlooked. In another category of cases, however,
the onset of the disease is evidently sudden, the attack
coming on in the course of a few days in persons pre-
viously healthy. Thus it sometimes develops after
sudden fright and grief, or after acute diseases or se-
vere hemorrhage. Cases of this kind must, however,
be regarded as constituting rather the exception than
the rule; but they are not the less worthy of attention,
since a knowledge of the possibility of their occur-
rence will serve to prevent many an error in diagnosis.
This form of onset is frequntly characterized by the
occurrence of one of those paroxysmal seizures so
peculiar to hysteria. We shall take occasion to refer
at length to those convulsive phenomena, in connec-
tion with the discussion of the motor manifestations
of the disease. For the present we will content our-
selves with observing that, although we shall adhere
as much as possible to a systematic discussion in the
following description, no corresponding chronological
order is really found in the disease itself. Indeed,

— 5 —
there is no affection in the whole range of medicine
the symptoms of which are subject to greater varia-
tions than those of hysteria. As a consequence, the
order of discussion adopted in any description is pure-
ly a matter of convenience, and is utterly devoid of
objective significance, as far as the disease itself is
concerned. Since mental disturbances are usually
among the earliest and most characteristic manifesta-
tions of the disease, it will be well to take up their
consideration first, though this is not the method
usually adopted in the books.

Psychical manifestations. — A certain mental exalt-
ation, accompanied by extreme irritability, is the most
obvious psychical symptom. The inhibitory power of
the intellect over the emotions seems suppressed; the
subject yields herself with apparent indifference to
sentiments of the most opposite character; joy suc-
ceeds sorrow, as evinced by alternate attacks of laugh-
ter and crying; there is an apparent complete paralysis
of volition.

As a direct result of these chaotic and ebullient
emotions, the patient becomes exhausted and peevish.
She is excited and moved to immoderate annoyance
by the veriest trifles; or perchance an exactly opposite
condition of things is engendered, and she signifies
approval in terms so extravagant as to cause amuse-
ment and astonishment to those about her. By de-
grees, however, the susceptibility to pleasant emotions
diminishes, as the exhaustion consequent upon the in-

— 6 —

ordinate psychical output becomes greater and greater.
And, as a final result, disagreeable emotions become
preponderant. At the same time a chronic tendency
to introspection becomes established, a condition
which culminates in one of the most disagreeable and
at the same time characteristic manifestations of hys-
teria, a morbid craving for sympathy. The subject be-
comes completely absorbed in what she considers her
deplorable condition, and thinks and talks of her ail-
ments without ceasing. As, by degrees, her friends
become accustomed to these lamentations, and by as-
cribing them to imaginary causes, fail to render the
customary sympathy, she becomes desperate. Her in-
ordinate egotism is offended; to her distorted vision
there is but one commanding personage in the uni-
verse— herself — in comparison with whom the rest of
mankind are as nothing. But, like many a royal
egotist, while heartily despising the ways of the ple-
bian portion of humanity, she is eminently anxious to
obtain its plaudits and servility. How to obtain an
endless sympathy from obdurate mankind, without
the slightest return, is the great question to the
hysterical, the cord from which all their present and
future hopes hang suspended. In order to obtain the
coveted boon, the whole moral nature is trampled
under foot; prevarication, false witness, theft, and
even murders, are the means to which resort is had,
when the milder expedients of constant lamentations
and weeping have failed to keep the sympathy of

— 7 —
family and friends up to the desired standard. These
crimes of the hysterical, committed apparently, in
many cases, without the slightest tangible reason,
form one of the most extraordinary chapters in the
whole range of criminal jurisprudence.

The following history, furnished by Cullingworth,*
is an illustration of a case of this kind:

" In December, 1876, a girl of eighteen was found
one evening standing, with her clothing wet and
muddy, and in an apparently stupefied condition, in
the closed doorway of a restaurant in the centre of
Manchester, a few yards from where she was lodging.
She was taken home and put to bed, and a medical
man was sent for. He found her to all appearance
unconscious of what was going on around her, and
uttering some disjointed and incoherent complaints of
having been drugged and threatened. He thought
she was recovering from the effects of some narcotic,
and did not at first pay much attention to her story.
The following day, however, she appeared worse, and
in the evening her condition was considered so critical
that the police were communicated with, with a view
to her statement being taken down. She was visited
by two experienced detectives, who, seeing how mat-
ters stood, and having the doctor's assurance that she
was in a dying state, sent at once for a magistrate,
before whom she made a solemn declaration to the

* Cited by Ross, op. cit., p. 855.

following effect: she believed herself to be dying. On
the previous evening a solicitor, at whose office she
had called on business, told her that she must go into
a convent, and gave her some sort of dark, sweet
drink, which rendered her senseless. On going down
stairs from the office, she met a Jesuit Father, whom
she had met once before. This gentleman pulled her
along the street to a little house in a court, where
there was an upper room with a bed in it, and a cross
on the wall. Having got her into this room, he said
improper things to her, and gave her a little cake,
which affected her directly. The woman of the house
came into the room and found her on the floor, after
which she somehow got outside; the priest following
her, again dragging her along in the dirt to the street
corner, when he ran away."

" The solicitor and the priest, both of them well
known and highly respected, were thereupon placed
under arrest in the middle of the night, on the charge
of having administered certain poisonous drugs with
intent to murder. The story was proved to be purely
imaginary, and the magistrate dismissed the case."

Self-mutilation is sometimes practiced by hysteri-
cal patients in order to obtain sympathy. The follow-
ing is a case in point, which was reported some years
since by Dr. Channing:*

" Mrs. Miller was first seen by us in 1875, a month

* American Journal of Insanity, January, 1878, p. 368.

— 9 —

after admittance to the asylum. She was an intelli-
gent German Jewess, rather below the medium size,
thirty years of age, hair and 'complexion light. She
was then thin in flesh, pulse weak, hands red and
cold, lips bluish, tongue pale and tremulous when ex-
tended; but few of her teeth remained, and her face
had a pinched look; her smile was very pleasant, but
her expression at other times was suspicious and irri-
table."

" She was in bed suffering from what seemed to
be a severe attack of hsematemesis; various remedies
were applied, but the hemorrhage continued several
days unabated. Her bodily condition continuing,
however, perfectly good, "notwithstanding the blood
lost, simulation was suspected; treatment was sus-
pended, and the bleeding ceased. The coffee-ground
appearance of ejected matter she had imitated by
vomiting food into her chamber-vessel and covering it
with blood (pricked and sucked from her gums) and
urine. This attack was followed by others of hysteri-
cal dysmenorrhoea and dysentery. Toward the end of
the month she became much depressed. * * * On the
25th of the month, in a paroxysm of despair, she broke
twenty-three panes of glass; with a small piece of glass
she cut her left wrist, and, inserted it into the wound,
endeavored to reach the arteries. * * * She was much
agitated, trembling from head to foot, and crying, but
however said nothing. The next day she was very
repentant for what she had done, and said that she

would never try to do it again; but in about three
weeks she again became 'discouraged,' to use her own
words, or depressed, irritable, and suspicious, and, be-
ing enraged because she had been refused opium, cut
her arms to avenge her wrongs. The wounds were
immediately below the elbow, on the inner surface of
the forearm, where the flexors are thickest. One cut
was six inches in length, the other four. * * * She
was crying, and endeavored to conceal the cuts when
seen, and would say nothing as to the situation or
number of pieces of glass she was said to have thrust
into the wounds." On examination under ether,
several pieces of g'ass were found in the wound and
removed. Subsequently, she v^^ounded herself in like
manner several times, with the result of finally setting
up an erysipelatous inflammation, which, in its turn,
was followed by oedema glottidis; suffocation appear-
ing imminent, tracheotomy was performed; on the
eleventh day the tube was removed, and the wound
healed in three weeks after the operation.

For some time subsequently she appeared to im-
prove; but after a time the mutilations were begun
afresh and continued more or less frequently until
June, 1877, when she cut herself for the last time, and
soon afterwards "broke her chamber-vessel to pieces
on the wall over her head."

" The following is a list of articles which have
been removed from her arms and saved: ninety-four
pieces of glass, thirty-four splinters, two tacks, four

shoe nails, one pin, one needle. Several pieces of
glass, and the pins and needles first removed, were un-
fortunately mislaid and lost. Including these, the
whole number of objects removed amounted to one
hundred and fifty. * * * The longest splinter
was nearly six inches long." * * *

" Strange as it seems, she apparently experienced
acute erotic pleasure from the probings which she was
subjected to." * * * u gj^g ^^g ]^qq^ ^ery hys-
terical, having frequent attacks of choking, globus
hystericus, and imagined at one time that she had a
spool in her throat, and could only swallow through
the hole in the middle."

This case is certainly unique, as regards the
character and extent of self -mutilation practised.

Dr. Channing also cites the case reported by Dr.
Robie,* of the Dundee Asylum, in which an hysteri-
cal woman swallowed a circular tea-cady, one and
one-fourth inches in diameter, with suicidal intent.

Dr. J. B. Andrews, of the Utica Asylum, has re-
ported a most interesting case, in which he removed
three hundred needles from the body of a female pa-
tient. The needles had all been inserted before she
became a patient in the asylum. The patient was
hysterical, and bore a strong resemblance, in some re-
spects, to the case of Mrs. Miller, f
• Soon after the introduction of anaesthetics, an

*Journal of Mental Science for July, 1875.

f Journal of Insanity for July, 1872; quoted bv Channing.

unusual form of accusation made its appearance in
court. These accusations were based upon the allega-
tions of certain women, to the effect that they had
been outraged while under the influence of an anaes-
thetic, in the office of a physician or dentist. Medico-
legal literature abounds in cases of this character.*
When these peculiar charges were first made in court
there can be little doubt that gross injustice was fre-
quently done, as both judge and jury were but too liable
to lend undue credence to the women declaring them-
selves aggrieved. In a short time, however, it became
evident to court and jurors alike that the women who
made these accusations had either labored under some
unusual mental aberration, incident to the inhalation
of the anaesthetic, or were the victims of some form of
neurosis. It was natural, under these circumstances,
that the thoughts of medical witnesses should revert
to hysteria; and accordingly, at the present day, the
connection of this insiduous affection with many cases
of this kind has been clearly made out.

The following are evidently cases in point: " In
1854 a clergyman's sister came to my office for the
purpose of taking ether and having a tooth extracted.

*Vide " Medical Jurisprudence " of Wharton and Stille.

"Artificial Anaesthesia and Anaesthetics," by Henry M.
Lyman, A.M., M.D., etc. New York: William Wood & Co.,
1881. Also

"A Manual of Medical Jurisprudence, by Allan McLane
Hamilton, M.D., Birmingham & Co., New York, 1883.

— 13 —
and brought her brother's wife with her. I began to
administer the ether to the patient, and whilst renew-
ing it she got away from me, and seemed alarmed and
offended. I did not attempt to compel her to breathe
any more ether, but urged her to take it, and so also
did her brother's wife; but she would take no more;
she had the impression, so her brother told me, that I
attempted to violate her, and that his wife assisted
me. It was a long time afterward before she would
fully give up that she was mistaken in the matter."*

The following case is quoted by Lyman :f "A
case of the utmost importance to the whole profession,
not in Great Britain only, but everywhere, was tried
before Mr. Justice Hawkins, at the assizes at North-
ampton, on the 9th of November. It was a charge
against a surgeon's assistant of criminal assault — of
rape upon a patient when under the influence of
chloroform. If there is a dastardly crime, it is to take
advantage of a woman's helpless unconsciousness to
violate her person. And so the magistrate thought,
who sent the accused to jail on the 14th of September,
declining to hear anything in his favor, and resolutely
refusing to accept bail. The charge was that a mar-
ried woman, named Child, went to the surgery of her
family medical attendant to have her teeth operated

*Dr. N. L. Folsom, in the Med. and Surg. Reporter for
January 12, 1877. Quoted by Dr. Lyman, op. cit., p. 95;

fContained in the Philadelphia Medical Times for De-
cember 22, 1877.

— 14 —

upon. She had been there a day or two before, but
the attempt to put her under chloroform had failed.
A second attempt was rather more successful. She
evidently had some peculiar idiosyncrasies in relation
to chloroform, for he gave it for an hour, and yet she
was never sufficiently under its influence to admit of
the operation being performed. She was accompanied
by a friend — a Miss Fellows. At the end of an hour
Miss Fellows went out of the room and saw Mr. Child.
In a quarter of an hour Miss Fellows returned. The
prosecutrix maintained that on Miss Fellows' return
she was quite conscious, but unable to speak. Find-
ing it impossible to perform the operation, the accused
accompanied the prosecutrix and her friend home.
So far Mrs. Child had been unable to speak, but
shortly after the accused left the house she complained
to her husband that he had taken advantage of the
absence of Miss Fellows to assault her criminally.
Next day, when the accused called, he was told about
what she had said, and he replied that she was labor-
ing under a.delusion. Under cross-examination, Mrs.
Child said that she told the accused that if he would
admit the offense and quit the town (Birmingham)
she would forgive him. This the accused declined to
do, denying that he had committed any offense. He
was then given into custody. The prosecutrix stated
that the offense was perpetrated immediately after
Miss Fellows left the room, that the prisoner went
upon his knees and then assaulted her. Miss Fellows

— In-
stated that on her return she found Mrs. Child in pre-
cisely the same position in the chair which she occu-
pied when she went out of the room. Such were the
facts of the case. * * * j^ ^^g meantime the un-
fortunate surgeon's assistant was sent to prison.

" When the case came to be tried, a large number
of medical men of repute came forward voluntarily to
aid the accused's defence, and did this quite gratui-
tously."*

A number of cases were related by medical wit-
nesses, in which females, undergoing operations at the
hands of dentists and surgeons, had alleged that they
had been criminally assaulted, persisting in this belief
in some cases for years afterwards.

Finally, the judge demanded of the jury whether
it was necessary to sum up, and they replied it was
unnecessary; they were already agreed upon a verdict
of acquittal. " Mr. Justice Hawkins pointed out that
such a verdict would not be the slightest imputation
upon the absolute sincerity of the prosecutrix, who, no
doubt, firmly believed every word of what she had
said. He then congratulated the accused upon hav-
ing had an opportunity of fully vindicating himself
upon the charge preferred, and said that the verdict
of acquittal did not mean that there was insufficient

*Among these witnesses, was the celebrated Dr. B. W.
Richardson, to whose testimony the subsequent acquittal of the
accused was in great measure attributable.

— i6 —

evidence, but that the accused was entirely cleared of
any imputation in respect to the charge preferred
against him. * * * The accused was then dis-
charged from custody, having been in prison two
months for no offence."

It is a common belief among certain persons that
the mental phenomena recorded above are due to
some extraordinary effect of the anaesthetic. But it is
a noteworthy circumstance that such cases are usually
observed among neurotic, hysterical females, or among
those in whom there is a strong erotic tendency. A
certain constitutional predisposition seems, therefore,
a pre-requisite in all'such cases. There can be little
doubt that such an hysterical predisposition was pres-
ent in the foregoing case, though the clinical history
is somewhat incomplete on this point.

When such instances occur, diligent inquiry should
always be made regarding the family history. The
discovery of the existence of consanguineous insanity,
or the affirmation of witnesses that the prosecutrix is
of a " nervous," hysterical disposition, should be ac-
cepted, in the absence of other more positive testi-
mony, as proof positive of the innocence of the ac-
cused. In our estimation the verdict rendered in the
case above cited was most just and in entire harmony
with the most enlightened scientific opinion.

Fictitious attempts at suicide are a favorite means
of attaining sympathy among hysterical women. An
instance of this kind came under my immediate notice

— 17 —

but a few weeks since. The history in brief was as
follows:

Mrs. C, a young woman of apparently robust
constitution, had been married but two years, when
she became feverish and restless, complaining that,
ever since the birth of her child, she " had not been
the same woman." She also developed the idea that
her husband was faithless in his marital relations, al-
though the latter gave constant and convincing proof
of his affection. Her constant complaining, and al-
ternate weeping and laughter, caused such pain and
annoyance to those about her that the family physician
was consulted on several occasions with regard to her
condition. On hearing that her medical adviser had
expressed the opinion that she was a sufferer from
hysteria, and that her sufferings were purely the pro-
duct of the imagination, she became very angry, and
declared that she was the victim of a "plot." Soon
afterwards, while the family were sitting at table, she
suddenly appeared m the room, and declared that she
had taken poison, exhibiting, in corroboration of her
assertion, a vessel containing a quantity of finely-
powdered glass. During the scene of consternation
which succeeded this tragic announcement, she pre-
served an imperturbable exterior, and seemed rather
gratified than otherwise at the sorrow depicted upon
the countenances of those about her. When, however,
the hastily summoned medical attendant proposed the
administration of an emetic, and at the same time

— i8 —

made preparations to introduce the tube of a stomach
pump, she protested vigorously, by word and action,
biting and scratching those who attempted to restrain
her. Finding, however, that her strength was failing,
and that she was about to be overpowered, she confess-
ed that she had not yet swallowed the broken glass, but
was about to do so in the presence of the family, in
order that her loss might be more "appreciated."

Such cases are common enough in practice, and
when the previous history of the patient is accessible,
they need cause but slight embarrassment.

It would be possible to multiply histories of like
character, growing out of a morbid desire for notoriety
and sympathy, almost ad infinititm. Medical and legal
literature abound in cases of this kind. Without
pursuing the subject further, however, we will content
ourselves with stating that such instances are by no
means confined to the female sex, but are found to
prevail among men, though to a less extent than
among women.

Besides the more pronounced mental phenomena
exhibited by hysterical persons, which the foregoing
description and cases have served to display, individ-
uals of this class are subject to various other forms of
psychical disturbance.

One of the most distressing mental symptoms
found in the hysterical consists in a persistent morbid
impulse to commit some act of violence. The objects
of such morbid impulses are usually found among the

— 19 —
immediate friends or family connections of the patient.
Thus I was consulted recently by a German as to the
mental condition of his wife, who had caused great
uneasiness by announcing that she was afraid to re-
main alone with her children, as she had an uncon-
trollable impulse to "throw them out of the window.''
She also begged her husband to remove a revolver,
which he was in the habit of placing under his pillow
at night, as she declared that she felt an almost resist-
less impulse to take the weapon and " shoot him in his
sleep." Her general mental condition was described
as "nervous," by which was meant that she was fretful,
feverish, and lachrymose. In appearance she is stout
and healthy, and the only derangement in bodily func-
tion is an occasional attack of dysmenorrhoea.

This morbid explosiveness, this tendency to com-
mit acts of violence, frequently finds expression in the
destruction of inanimate objects. This form of men-
tal disturbance is prevalent among young girls of hys-
terical tendencies. Instead of the irritable and ex-
plosive tendencies finding vent in violent conduct
toward individuals, the destructive impulses are di-
rected towards the inanimate environment. The bed
clothes are torn into shreds ; tapestries are pulled
down ; the clothing is thrown about, and the furniture
broken in pieces. Sometimes the house is set on fire, and
the most incredible intrigues concocted against friends
and acquaintances. In many instances, as we have
seen, the subject seeks to gain sympathy and notoriety

by her extraordinary conduct ; and to attain this end
she does not hesitate to lie, defame at, or even commit
murder. On the other hand, in not a few cases, it is
utterly impossible to ascertain the slightest motive for
the commission of the various heinous crimes of which
the hysterical are guilty. Sometimes the duplicity of
hysterical women is so profound as to baffle the efforts
of the most expert medical witnesses. As a conse-
quence, the ends of justice are frequently perverted,
and on more than one occasion perfectly innocent per-
sons have suffered at the hands of the law for crimes
which have subsequently been shown to be the acts of
hysterical females. From what has been said, it is
evident that the medico-legal relations of hysteria are
of the utmost interest and importance. Were this the
proper occasion an entire chapter could well be de-
voted to this branch of the subject ; but as such a
digression would evidently transcend the scope
of the present work we must content ourselves
with referring to the excellent book of Legrand du
Saulle,* and the more recent little work of Dr. Allan
McLane Hamilton, which certainly constitutes a valu-
able contribution to legal medicine.

Hysteria is frequently complicated with mental
disturbances of such profundity as to constitute a ver-
itable "insanity." By this we mean that the psychi-
cal disturbances attain the gravity of mania or melan-

■^Les Hysteriques etat physique et etat mental, etc., par
le Dr. Legrand du Saulle, Paris, 1883.

cholia, with sexual or uterine symptoms, feigned bod-
ily affections and other deceptions, practiced with a
view to obtain sympathy; and a morbid irascibility
and erotomany. The erotic tendencies may be con- ^
cealed at first ; but careful interrogation and observa-
tion almost invariably end in their discovery.

The threats and abortive attempts at suicide re-
sorted to by the patient have usually little significance,
and rarely result in grave consequences. Hysterical
convulsions and retention of urine, of which we shall
take occasion to speak later, are sometimes present.

Sometimes the diagnosis of this form of mental
derangement presents peculiar difficulties, and there
is great liability of confounding it with masturbational
and "adolescent" insanity. The most we can do
when doubts of this character arise is to postpone a
definite verdict until all the facts in the case are thor-
oughly known. We should, moreover, guard against
pronouncing a case one of hysterical insanity until we
have become thoroughly convinced that the hysterical
symptoms constitute its most prominent feature.

Of hysterical insanity Clauston observes : " The
fasting girls, the girls with stigmata, those who see
visions of the Saviour, and the saints, and receive
special messages in that way, the girls who give birth
to mice and frogs, and those who live on lime and
hair, are all cases of this disease."*

*0p. cit., p. 331 -

The following case, quoted from Clauston, is a
fair illustration of hysterical insanity : " J. U., age
21, of nervous and excitable temperament; habits
correct. An epileptic. Had on one occasion at
home a mild attack of what must have been sub-acute
maniacal excitement. The cause of the present attack,
which had lasted for four days, was a fright which first
produced ordinary hysterical symptoms, and then
maniacal symptoms engrafted on them. She shouted
and screamed, and spoke of hearing God speaking to
her, and would rush to the window to jump out. She
imagined she was a most important person, attitudin-
ized, and did everything to attract attention to her-
self. Attention and sympathy were craved by her,
and if she could not get them in one way she tried
another. She refused her food, saying it was pois-
oned, but took it rather than be fed with the stomach
pump. She had raenorrhagia, and was most mi-
nute and circumstantial in the details as to her
health. She was tried with hyoscyamine, valerian,
and monobromide of camphor, with apparent benefit ;
but I consider the greatest improvement was produced
in her case by discipline, work, open air exercise, ton-
ics, and good plain food in abundance. She improved
at first, and once or twice relapsed, but in two months
she recovered and was discharged. I do not like to
keep hysterical cases too long in the asylum after con-
valescence, as a general rule, for they sometimes get
too fond of the place, preferring the dances, amuse-

— 23 —
ments, and general liveliness of asylum life, even with
its restrictions, to the humdrum and hard work of
poor houses."*

The following is an exceedingly characteristic let-
ter of a maniacal hysterical girl, and seems to illus-
trate in a striking manner the morbid psychology of
the subject : f

" My Dear Mamma — It is time that I leave to re-
turn home. I have been tremendously changed for
the better. I think papa will be able to get me a com-
mission under Garibaldi before long. There are three
to whom I am especially indebted — one Mr. C, the
modeller, the other, the doctor, a eunuch who mod-
elled me at the fire and attended me and bathed me.
He is, I am sure, a gentleman, a splendid doctor.
Could not papa get him into a regiment abroad?
And there is the nurse. Could not papa get him a
situation away from Morningside Asylum, where I am
at present ? I should like papa to come for me as
soon as possible. Do you remember the verse, " There
are," etc. (12th verse, ix. chapter of Matthew) about
eunuchs ? Then I beg to inform you that, according
to Scripture and my conscience, Jessy, your cook, is

*" Clinical Lectures on Mental Diseases," by T. S. Claus-
ton, M. D.. etc., Philadelphia, 1884.

f Taken from the " Morosonian Lectures," by Drs. Skaal
and Clauston, for 1873, Journal of Mental Science" vol. xix,
p. 500; vide also "Clinical Lectures on Mental Diseases," by
T. S. Clauston, Philadelphia, 1884-1885, p. 341.

— 24 —

a man ; and Janet, the mad devil, is a man ; and D.
and H., boys, who can have children. Aunt I. is a
man, and yourself also, both made of men, and I am
a boy, made of Dr. C. and Dr. Z. Mrs. T. is a man
made of men. They are very ignorant on this sub-
ject here ; but as for me, it is certain that at least the
spirits have shown me, which Christ sent me when I
was under drugs ; they showed me this. I have at
times since I come here passed the shadows of death,
and therefore am authorized to speak in opposition to
all men and women, gentlemen and ladies, who oppose
me. I am, I can swear, as you want to know what sex
I belong to, a mixture of a nymph and a half man,
half woman and a boy, and a dwarf, and a fairy. I
know more than my fellow mortals, have expired
eleven times before the time. — I am, etc."

CHAPTER 111.

SENSORY DISORDERS— HYPER/ESTHESIA.

Hyperaesthesia is an almost invariable accompani-
ment of hysteria, and may involve a portion or all of
the special senses. Sometimes there is an abnormal
increase in the acuteness of the perceptive faculties;
so that it is a subject of common remark, even among
the laity, that hysterical persons see, hear, smell, and
taste with greater keenness than those in health.
Again there may be a certain degree of sensory per-
version, manifested by a dislike for certain stimuli
which by the healthy are looked upon with indiffer-
ence or even regarded as pleasurable. Or there may
exist a positive liking for sensations which, to the
majority of mankind, are regarded with feelings of
repugnance.

Coupled with these anomalies of sensation, there
exists, in the majority of cases, a corresponding per-
version of the higher mental faculties — a veritable
'■''psychical hypercBsthesia," as Jolly calls it. We have
already discussed the various mental disorders of the
affection, which may properly be comprised under this
heading, in the previous paragraph, and therefore ab-
stain from further particularization on the present
occasion. Coeval with these sensory disturbances,
certain anomalies of perception appear, which, in the
absence of all primary excitement of the peripheral

— 26 —

apparatus, cannot be regarded otherwise than as
purely subjective. It is thus that the true hallucina-
tions of hysteria originate — phenomena which un-
questionably lie at the root of the illusions and delu-
sions of the more serious mental complications of the
affection.

Perversion and exaltation of the senses of smell
and taste are especially frequent. The subject de-
clares that she detects odors of an agreeable or
repugnant nature, which remain imperceptible to those
about her; and careful investigation shows that she
really is able to discover the presence of astonishingly
minute quantities of semi-inert substances. With this
unusual power of perception there is often marked
sensory perversion, manifested in a strong dislike for
certain substances which by healthy persons are con-
sidered to possess an agreeable taste or odor. Or the
process is reversed, the subject expressing herself as
delighted with the odor and taste of the most disgust-
ing substances. Thus a lady afflicted with hysteria
confessed to me that the odor of excrement was
agreeable to her; while another patient, a young girl,
tells me that the odor of eau de cologne excites in her
feelings of the liveliest repugnance.

Cases exhibiting a decided increase in the acute-
ness of the sense of smell are found in the literature
of the subject, and are by no means as rare, according
to my experience, as some writers appear to imagine.
For example, the lady above referred to declared that

— 27 —

she was able to detect the presence of her four-year-
old child by the aid of the sense of smell, when the
latter entered unexpectedly a neighboring apartment;
and a hysterical boy whom I have recently seen is
able, according to his father, to appreciate the pres-
ence of a dog or cat, even when the latter are at some
distance and totally invisible. Doubtless similar in-
stances will occur to most physicians of extended ex-
perience.

When hallucinations of smell and taste exist in
complicated cases, they are said to particularly facili-
tate the establishment of more or less permanent
delusions.*

I cannot say that my own experience agrees en-
tirely with the foregoing, since I have found that
hallucinations of other senses, particularly those of
hearing, are quite as prolific of erroneous ideas as
those of smell and taste.

Hyperaesthetic conditions of the organ of sight
are frequently met with. Sometimes the subject com-
plains that bright light is disagreeable to her, and
resort is had to colored spectacles, which may afford
apparent relief. In other cases the photophobia is so
great that the afflicted women seclude themselves in
darkened rooms for days together, refusing food ex-
cept when brought to them. Sometimes the hyper-
sensitiveness is only apparent in connection with

* Vide Jolly on Hysteria, op. cit., p. 497.

— 28 —

certain colors, especially red. Subjective sensations
of light, assuming the form of spots, flashes, and
sparks are also observed. In some cases, the subjec-
tive appearances attain to the dignity of veritable hallu-
cinations, which may be agreeable or repulsive in
character. The physiological substratum of the con-
dition known as ecstacy is unquestionably to be sought
after among these visual hallucinations.

Sometimes the subject recognizes the subjective
nature of many of these impressions; but in other
cases it is impossible to convince her of the unreality
of the phenomena. Under the latter circumstances
delusive opinions may arise.

In some cases there is a manifest increase in the
acuteness of vision, which is not to be accounted for
merely on the score of a prolonged sojourn in a dark-
ened room. The extraordinary narratives of the vis-
ual powers of hysterical persons, in which the latter
are said to read with their back turned or with closed
eyes, are evidently unconscious perversions of the
truth or gross deceptions.

The sense of hearing is often exaggerated in hysr
terical persons to such a degree that they readily ap-
preciate sounds which are imperceptible to healthy
mdividuals. So sensitive do they become to sound
that such an ordinary occurrence as the squeaking
of a door, the rumbling of a cart, or the cry
of a child is sufficient to cause the most intense
annoyance. Subjective sensations, such as ringing.

_ 29 —

blowing, roaring, humming, and singing are frequently
encountered; and true auditory hallucinations are also
met with. As we have already had occas.on to
observe, the latter frequently result in establishment of
more or less pronounced mental aberration.

In almost all cases of hysteria there is present a
morbid sensibility to pain. This exalted susceptibility
to painful impressions may be confined to the skin or
may involve the more deeply seated tissues. It is sub-
ject, moreover, to irregular topographical distributions.
This is particularly true of cutaneous hypersesthesia,
which, though sometimes general — being distributed
over the entire surface of the body — is often confined
to certain isolated regions of the integument. Some-
times the skin of one half of the body, or one or more
extremities, or of certain portions of the trunk, is alone
affected. In yet other cases hyperaesthesia and anaes-
thesia are encountered side by side, or at all events
isolated anaesthetic islands are found in the midst of
more or less extended hyperaesthetic areas. These
curious phenomena certainly constitute a most enig-
matical chapter in pathology; but it would be a practi-
cal waste of time to examine the various more or less
ingenious hypotheses which have been advanced with
a view to their explanation.

When the cutaneous hyperaesthesia is general, the
patient suffers great torture on attempting to execute
such simple movements as turning about in a chair or
dressing. In the more exquisite cases, the mere im-

— 3° —
pact of the bed-clothes is sufficient to cause acute
pain, and in some instances convulsions.

Besides the hypereesthetic phenomena above re-
ferred to, almost all hysterical individuals complain of
pain, which may be diffuse in character or confined to
the most diverse localities. Sometimes the pain is
felt over the entire extent of the abdomen, and may
be associated with tympanitis. x\t others neuralgic
pains are present in the mammary glands, the latter
being often of such intensity as to render the contact
of the clothing or bed-linen absolutely unendurable.
The hyperaesthesia is particularly marked during the
menstrual period. Cardialgia is another frequent
symptom of hysteria, and one which is often associated
with more or less persistent vomiting — a combination
of symptoms which may give rise to the erroneous
preconception that we have to do with perforating
ulcer of the stomach. This impression is furthermore
enhanced by the fact that hysterical females are often
great gourmands, devouring everything set before
them with an appetite apparently insatiable. It is evi-
dent that such persistent gluttony can only result in.
an aggravation and perpetuation of these digestive
disturbances; indeed, I am not sure but that this over-
loading of the stomach constitutes the starting point
of many of the gastric disorders to which the hysteri-
cal are liable.

Hysterical persons are often afflicted with an
hyperaesthetic condition of the ovaries, associated, in

— 31 —

many instances, with anaesthesia of the same side.
At the same time they complain of irritation about the
external genital organs, associated with a morbid in-
crease of sexual excitement. This latter condition,
which is particularly pronounced at the time of men-
struation, may give rise to reflex spasm of the sphincter
muscle (" vaginismus ")* a state of things peculiarly
unfavorable to coitus. Owing to the irritated condi-
tion of the urethra and bladder, which is an almost
constant concomitant, the desire to urinate is frequent,
and the act is rarely accomplished without consider-
able pain.

Dorsal pain is a more or less frequent accompani-
ment of hysteria. Sometimes it is situated in isolated
spots between or above the scapulae, at others it is dis-
tributed in a more or less continuous band along the
course of the vertebral column {spinal irritation). In
the more exquisite cases the slightest pressure above
the vertebrae is sufficient to cause severe pain, while
the passage of the wire-brush, with a moderate cur-
rent, along the spine is sufficient to reveal the presence
of hyperaesthetic spots, in the less severe cases. Sensi-
tiveness of the uterus, though not a constant symptom
as formerly supposed, is frequently met with; and
while doubtless dependent, in some instances, upon

*Vide the writings of Drs. J. Marion Sims and T. Gail-
lard Thomas; also, Axenfeld et Heuchard. " Traite des
nevroses," Paris, 1883.

— 32 —

uterine disease, must in man}- other cases be regarded
as of purely neurotic origin.

Thus cases of uterine pain are often met with in
those who have been treated for protracted periods
for some form of supposed disease affecting the uterus
without the slightest beneficial result. But when
placed upon the back and treated according to the
system of spinal rest so ably advocated by Mitchell,
they often display astonishing improvement in a short
space of time.

Of great theoretic and practical interest are the
pains occurring about the joints of hysterical persons
pains which are frequently mistaken for symptoms of
true articular disease.

To Sir Benjamin Brodie* has been ascribed the
credit of having directed the attention of the profes-
sion to the frequency of these enigmatical symptoms.

When pressure is exercised upon the joints of
those affected by this form of articular neurosis,
severe pain is produced. It is evident, however, that
this pain is located in the soft tissues about the joint
rather than in the latter, since the forcible apposition

*Brodie, Sir Benjamin, " Lectures Illustrative of Certain
Local Nervous Affections," London, 1837. Also Esmarch,
Ueber " Gelenkneurosen," 1872. Stromeyer, " Erf ah run gen
ueber " Localneurosen," Hanover, 1873. Werner, "Ueber
Nervose Coxalgie," Deutsche Zeitschrift fuer Chirurgie, Band
L Berger, " Zur Lehre von den Gelenkneuralgien," Berliner
Klinische Wochenschrift, 1883.

— 33 —

of the articular surfaces fails to produce the disagree-
able symptoms and shock peculiar to true joint-dis-
ease. Atrophy of certain muscles has been noted by
some observers,* after the affection had continued
for a series of years. It is probable, however, that
the attenuation of the muscles is never so great as in
organic disease of the joints.

The articulations most frequently involved are
the knee and hip joints, but even the smaller joints of
the wrists, ankles and, fingers are sometimes af-
fected.

It is evident that an accurate diagnosis in cases
of this kind is of the utmost importance, since, if the
affection be mistaken for true joint trouble, the patient
is liable to all the inconvenience arising from pro-
longed antiphlogistic and orthopaedic treatment. Be-
fore delivering a final opinion, therefore, the patient
should be subjected to a rigorous physical examina-
tion. At the same time the most searching inquiry
should be instituted regarding her general physical
and mental health, with a view to discovering any in-
dications of hysteria or other neurotic trouble. Not
until we have exhausted the last resources of investi-
gation are we justified in forming a definite conclusion
as to the nature of the affection.

*Vide "Nervous Mimicry of Organic Disease, by Dr. J.
Paget. The Lancet, Vol. II. 1873.

— 34 —

The following cases reported by Skey* are fair
illustrations of these joint affections:

"Annie W , aged twenty-two, was admitted

into Treasurer's Ward in the spring of last year. She
had been confined to her bed for twelve months, and
was sent up from her parish, near Bedford. During
twelve months she had been totally deprived of motor
power in the left leg, and during ten months in the
left arm. The two extremities lay on the bed perfect-
ly motionless and paralytic. Indeed, her case was re-
ported to me as one of hopeless and incurable palsy.
There was something strange in the girl's aspect, and
in the total absence of motor power extending to the
toes. A truly paralytic limb is rarely so dead as these
limbs were; we can often obtain some sligh manifesta-
tion of volition, even though in the slightest motion
of one or more of the toes. In this case there was ab-
solutely none detectable to the eye. I suspected it to
be a case of hysteria, and ordered her valerian and
ammonia in full doses after the first three days; meat
diet and porter. In four days movement on voli-
tion was perceptible in all the toes and in the hand.
In a fortnight she could move her arm and leg slowly
in all directions. In one month she walked on
crutches about the ward, and in six weeks she left the
hospital convalescent."

* " On Hysterical Affections of the Joints," by Frederic
C. Skey. F. R. S. The Lancet, March 12, 1859.

— 35 —

The history of the above case is not as complete
as might be desired; but the following instance, quoted
from the same author, is more to the point:

" Eliza J , aged twenty-two, was admitted in-
to Treasurer's Ward in April last with an affection of
the knee, which incapacitated her for movement of
any kind on the affected limb. The joint was scarcely
perceptibly swollen, yet she could not bear the most
superficial examination by the hand without an ex-
pression of pain quite disproportionate to the apparent
amount of disease. The temperature of the joint was
slightly, but not much, increased. The only explana-
tion obtainable from the girl's statement referred the
injury to a fall six weeks prior to her admission, and
three weeks before the first appearance and even the
suspicion of disease. During the interval of the first
three weeks, she " thought the joint felt occasionally
more stiff than usual." This girl had a somewhat
florid complexion; she had a weak pulse, and, as almost
a matter of course, had cold feet and severe headaches.
Both sides of the joints bore marks of previous treat-
ment in the form of pretty active scarifications. It
appeared that blood had been taken from the joint by
cupping on two occasions, to the extent, as nearly as I
could learn, of about twelve ounces; and a blister of
some magnitude had been applied on its front surface.
From these remedies I could not ascertain that any
benefit had been derived to the affected knee, and she
thought, on the whole, her attacks of. headache had

- 36 -

been more frequent and severe. Her bowels were
habitually constipated. I ordered her the local appli-
cation, for three or four consecutive nights, of a lini-
ment composed of two drachms of the fluid extract of
opium to an ounce of compound soap liniment, and
the joint to be rolled with flannel; twice a day a
draught of ammonia and valerian; full diet with a pint
of porter daily. The local application was continued
with intervals, for eight or nine days, with much re-
lief and without return of pain. At the expiration of
a fortnight the medicine was changed to eight-grain
doses of ferro-citrate of quinine, and she left the hos-
pital in five days convalescent."*

* Other contributions to the literature of the subject are:
" Nervous Mimicry of Organic Diseases," by Sir. James Paget,
The Lancet, Nov. i, 1873. " Paralysie hysterique, attitude
vicieuse, pied bot consecutif," by N. Damaschino, Gazette des
Hopitaux, 1879, P- 5^- "Diseases of the Nervous System,"
Lecture on, by Francis E. Anstie, M. D., The Lancet, 1873,
Nol. I., pp. 437-

CHAPTER IV.

SENSORY DISORDERS CONTINUED. — ANAES-
THESIA.

AncBsthesia. — Sensibility is frequently diminished
or even entirely lost in hysteria. Sometimes the an-
aesthesia is circumscribed in character, as we have
already had occasion to observe, whereas in a certain
per cent, of cases it may involve the greater portion
of the integument, and even extend to the muscles
and other deep-seated tissues. Nor do the nerves of
special sense escape; but, on the contrary, as we shall
presently see, their implication often gives rise to pro-
nounced functional impairment. Cutaneous anaes-
thesia usually appears after an hysterical attack, and
is liable to aggravation from subsequent seizures.
The anaesthesia thus induced exhibits certain ambli-
tory characteristics of a most interesting nature from
a clinical standpoint. Thus, after a fresh attack, the
anaesthesia may apparently disappear; but, on careful
examination, other parts are found to be affected. Or,
the previously anesthetic portions of the integument
may become hyperaesthetic.

Sometimes tactile and thermic sensibility as well
as sensibility to pain are impaired or lost; but as a
rule the capacity to appreciate pain is alone affected.
The distribution of the anaesthesia is subject to great

variation. In a considerable number of cases it is
situated on the dorsal aspect of the hands and feet; in
another category of patients one or more limbs are in-
volved, whereas in a small per cent, of cases it is
limited to one-half of the body. Anaesthesia of the
entire integument is least frequently met with.

Anesthesia of the various mucous membranes is
frequently encountered, and gives rise to a variety of
secondary phenomena. Thus, if the nasal mucous
membrane be anaesthetic, irritating substances and
tickling fail to cause sneezing. If the conjunctiva
be affected it may be touched and irritated by foreign
substances without giving rise to a flow of tears or
reflex spasm. In anaesthesia of the pharynx and
adjacent parts, the membrane in question may be
titillated and otherwise irritated without giving rise to
vomiting; and if the loss of sensibility be very exten-
sive, taste and smell may be abolished. That the
bladder and rectum may sometimes be involved seems
probable from the fact that they are sometimes
greatly distended by the accumulation of feces and
urine, a condition which causes the patient no appre-
ciable discomfort.

The mucous membrane of the vulva and vagina is
frequently profoundly anaesthetic. It is this condition
which causes that complete loss of sexual appetite
sometimes observed in married women, a state of affairs
prolific of conjugal unhappiness.

As we have already had occasion to remark, the

— 39 —
special senses frequently become anaesthetic after
severe hysterical attacks. Sometimes the sense of
smell and taste may be entirely lost; at others the
sensory impairment is unilateral. Unilateral and even
bilateral deafness are sometimes observed in the ab-
sence of all disturbances affecting the peripheral ap-
paratus of hearing.

More or less profound visual disturbances are
also encountered among the hysterical; the most fre-
quent of these is probably unilateral amblyopia. Com-
plete amaurosis is, however, also observed. Of
ninety-three cases of ansesthesia of different sensory
districts examined by Briquet,* amblyopia was present
in six instances.

Without entering upon a further consideration gf
these anomalies of vision, which have been exhaust-
ively discussed by Charcot and others, I will simply
observe that examination with the ophthalmoscop
usually fails to reveal any noteworthy changes in the
disks. The case described by Galezowsky exhibited
infiltration and capillary reddening of the disk; but
the amblyopia had existed for a long time without
opthalmoscopic changes, and it is consequently reason-
able to infer that the latter were induced by some
unknown intercurrent causes. In accordance with
what we already know of the amblitory nature of

* Quoted by Jolly, op. cit.

— 40 —

hysterical symptoms, we are not surprised that both
hysterical blindness and deafness sometimes suddenly
disappear and give place to other phenomena.

CHAPTER V.

MOTOR DISORDERS.— SPASMS.— PARALYSIS.

Motor Disorders. — The phenomena of motility,
like those of sensibility, may be exaggerated or
diminished.

Spasms. — These may be of a tonic or clonic na-
ture, and are manifested either as circumscribed
twitchings of individual muscles or groups of muscles,
or as convulsions involving the motor apparatus, more
or less extensively.

When the spasm is located in the pharynx and
oesophagus, it gives rise to the sensation of choking
known as globus hystericus, a term which has been ap-
plied to this condition from the fact that the subject
complains of feeling a ball in her throat. So con-
vinced are most females of the objective reality of
these sensations, that they make the most strenuous
efforts to swallow the foreign body, apparently lodged
in the throat; and, failing in this, they attempt to dis-
lodge it with the finger, or by the aid of a hair-pin.
In certain cases the spasm of the oesophagus may be
so severe and persistent in character as to induce the
belief that organic stricture is really present. When
the spasm extends to the tongue, which occasionally
happens, the organ is distorted' to such a degree as to
greatly interfere with articulation and swallowing.

Sometimes, too, the stomach becomes involved in

— 4^ —
the spasm, and, consequently, the retention of food
becomes almost impossible, the subject vomiting her
food immediately after it had been swallowed. Peris-
taltic movements of various portions of the intestines,
accompanied by borborygm, eructations and colicky
pains are sometimes present. When this spasm of the
intestine become localized and persistent, stricture
may be produced. As a result of this condition the
progress of the foeces is impeded, while at the same
time, owing to the incarceration of gas above the point
of constriction, the bowel becomes so distended as to
give rise to the phenomenon known as a " phantom
tumor." Sometimes, however the results of the per-
sistent spasm are even more serious, and a veritable
intestinal obstruction may occur.

The genito-urinary apparatus may also become
the seat of spasm, and in a considerable percentage of
cases the latter gives rise to spasmodic retention of
urine, which is, curiously enough, associated with a
persistent desire to urinate. This desire to micturate
is explicable in most cases by an unusually hyperses-
thetic condition of the bladder, which may or may not
be associated with irritability of the vagina and vulva.

When the hyperaesthesia of the genital organs is
great, reflex activity is sometimes increased to such a
degree as to render coitus impossible. Under these
circumstances the mere contact of the male genital
organs with the vaginal orifice is sufficient to provoke
severe and painful vaginismus. Concerning the causa-

— 43 —
tion of vaginismus, Scanzoni published some interest-
ing statistics in 1868. These observations have been
summarized by Dr. T. Gaillard Thomas* as follows:
"During the preceding three years he (Scanzoni) had
seen thirty-four marked cases, due chiefly, he thought,
to violent efforts at sexual intercourse, practiced upon
women having small vaginas and well-developed
hymens. Scanzoni found that twenty-five of his thirty-
four patients had various functional and organic diffi-
culties, which in twenty cases had come on after
marriage; in eleven there was congestive dysmenor-
rhoea; in one, amenorrhoea had existed for three years;
in thirteen, there was chronic metritis; four had either
ante or retroversion; in one there was perimetritis; in
seventeen, chronic uterme catarrh; in fourteen, vagi-
nal catarrh; in one, anteflexion; in two, retroflexion;
nine had urinal difficulties; one had inflammation of
the right Bartholin's gland; in fourteen there were
symptoms of anaemia; and in seventeen of hysteria.'" \

And continuing. Dr. Thomas \ proceeds to state
that: "Although the sexual act could not be fully
completed, conception was not entirely impossible, as
out of the thirty-four cases two had conceived; in the
other thirty-two, sterile marriages had existed from one

* A Practical Treatise on the Diseases of Women, by T.
Gaillard Thomas, M. D., Philadelphia, 1878, p. 143.
f The italics are ours.
X Op. et loc. cit.

— 44 —
to eleven years. This sterility was not due to want of
sexual desire, but arose entirely from spasm involving
all the muscles of the pelvis, which also rendered ex-
amination, either by the touch or speculum, impossible
without the use of an anaesthetic."

The hysterical attack, which we shall presently
take occasion to describe more in detail, is frequently
characterized by screaming, crying and laughing of a
more or less spasmodic nature. In this connection it
is well to bear in mind that the spasmodic closure of
the glottis, which sometimes takes place during these
seizures, may give rise to dangerous dyspnoea. Con-
sequently, the medical attendant should be prepared
to act with energy and precision.

Of diagnostic importance only secondary to globus
are the more or less incessant facial contortions, the
"facies hysteria" of the older writers — an appearance
characterized at once by a certain fulness of the cheeks
and a drooping of the eyelids.

Paralysis. — Complete or partial loss of muscular
power is frequently present in hysteria. Sometimes
the paresis is exceedingly limited in character, involv-
ing but one or two small muscles. Thus it is probable
that the drooping of the eyelids, so characteristic of
hysterical women, is due to weakness of the lavator
palpebrae superiosis muscles. In some cases, however,
the paralysis is much more extensive, involving one or
more limbs, or assuming the form of hemiplegia or
paraplegia.

— 45 —

The evolution of these motor disturbances is, in
some cases, extremely gradual, the first symptom
worthy of note being a sensation of weakness or
heaviness in the affected extremities. Sometimes,
however, the advent of the paralysis is sudden, and
takes place without the slightest warning, usually after
an hysterical seizure.

In cases of hysterical paraplegia, in which the
muscles of the lower extremities are only partially or
slightly affected, the patient is able to walk about by
the aid of a cane or crutch; when, however, the motor
disturbances are more profound in character, she may
be confined to her bed.

With the more or less extensive paralysis of hys-
teria, anaesthesia is frequently associated. Sometimes
cutaneous sensibility is alone affected; but, on the
other hand, in not a few cases the anaesthesia extends
to the subjacent muscles.

Like so many of the other symptoms of hysteria,
these paralytic phenomena are often amblitory and
evanescent in character. Sometimes they disappear
from one side of the body only to reappear on the
other. Sometimes, again, the paralysis may persist
for a few days, weeks, or months, and then suddenly
disappear altogether. But it would be a mistake to
infer from such disappearance that the subject is
henceforth exempt from accidents of the kind, since it
not infrequently happens that, even after the lapse of
several years, the paralytic symptoms again return
subsequent to an exceptionally severe seizure.

- 46 —

With regard to the differentiation of the paralytic
phenomena of hysteria from true paralysis, resulting
from organic lesions, this much may be briefly stated:
That hysterical paralysis is, almost without exception,
accompanied by the psychical disturbances, hyperaes-
thesia, spasms, and numerous other manifestations of
the disease; so that the evidence afforded is so preg-
nant that mistakes are usually easily avoided.

After all has been said, however, which the sub-
ject admits of, it must be admitted that where the
typical hysterical phenomena are slightly pronounced
errors are extremely liable to occur. But to admit
this fact affords no extenuation for those errors
in diagnosis and treatment which are so constantly
perpetrated, even where the evidence is most con-
clusive.

Before concluding the consideration of the motor
anomalies of the affection, a word respecting those
contractures which have been so repeatedly and ably
described by recent French authors.*

When tonic spasms in the muscles of the limbs
are both severe and persistent, certain distortions of
the latter are produced, which may be evanescent or
recurrent in character, or may persist for a series of
years. If the contracture be situated in the upper ex-
tremity, the forearm, hand, and fingers are rigidly

* Vide Charcot, " Lecons sur les Maladies du System
Nerveux," Paris, 1872-1873. Also, Bourneville et Voulet,
" De la Contracture HyKterique," Paris, 1872.

— 47 —

flexed, so that extension is often impossible. But if
the spasmodic condition be present in the lower limb
the latter is extended upon the pelvis and the leg up-
on the thigh. At the same time the foot usually as-
sumes the attitude of talipes equino-varus, while,
owing to spasm of the adductors, the thighs are rigidly
approximated.

Sometimes these contractures may persist for a
series of years and then disappear without other warn-
ing than some form of violent mental disturbance.
The final result is not, however, always so fortunate;
since, after the contracture has continued for a long
time, atrophy of the affected muscles may occur. If,
under these circumstances, a careful electrical exam-
imation be instituted, it is often possible to demon-
strate a well-marked degenerative reaction.

Tremor is sometimes observed to accompany
these contractures, and may be evoked by any sudden
tension of the muscular system. In exquisite cases
the knee-tendon reflexes may be exaggerated. In a
case of this kind, in which the contractures had per-
sisted for many years, Charcot* was able to demon-
strate, by post mortem examination, sclerosis of both
lateral columns of 'he cord. To infer, however, from
this fact that the presence of tremor in these cases is
an infallible indication of an organic lesion of the
lateral columns is manifestly impossible, since recovery

* Cited by Bourneville, op. cit.

sometimes takes place after the tremulous condition
has persisted for a long time. On the other hand it
is possible, and perhaps even propable, that in old
contractures with atrophy a lesion more or less per-
manent in character is actually present; and, further-
more, it is even conceivable that such a lesion might
extend to the anterior horns of gray matter. Assum-
ing this to be the actual state of things, both the per-
manent contracture and subsequent atrophy are easily
accounted for. Speculations on this point are, how-
ever, of little avail in the present state of knowledge;
and, in spite of the mterest attaching to Charcot's
case, a single instance of this kind cannot set at rest a
question of such magnitude. Evidence in corrobora-
tion or rebuttal is, therefore, in order.

It should be borne in mind, in this connection,
that tremor is not, however, necessarily always accom-
panied by contracture, but may exist quite independ-
ently of the latter. I have at present a case of this
kind under treatment. The patient, a young man of
thirty, exhibits a variety of hysterical mental and
physical symptoms, and not the least interesting feature
in the case is persistent tremor of the facial muscles,
which is also present to some extent in the hands.
There is, however, no tremor in the tongue. The
tremulous condition, which I have already succeeded
in ameliorating to a considerable extent, is excited by
insignificent emotional disturbances, and resembles
closely the tremor of paralysis agitans.

CHAPTER VI.

VASO-MOTOR DISORDERS— THE HYSTERICAL
COUGH.

Vaso-motor Disorders. — These are frequently ob-
served in hysteria, and may consist in a local diminu-
tion in temperature — a condtion peculiarly prone to
occur in hysterical joint trouble, as Brodie and others
have observed; or the vaso-motor insufficiency is ex-
hibited in frequent and unaccountable blushing. Car-
diac derangements of a functional nature are also
frequent accompaniments of hysteria, and are usually
associated with general anaemia.

The various miraculous accounts of hysterical
persons, whose wounds "emitted little or no blood,"
are probably founded upon the observation that bleed-
ing is much less profuse in the anaesthetic regions of
such individuals than in other portions of the body.
Charcot, I believe, was the first to draw attention to
this fact.

Remarkable and sudden elevations of tempera-
ture are sometimes observed in hysteria. These ther-
mic variations have been recorded in medical literature
by a number of reliable witnesses; so that, although
intentional deception has undoubtedly been resorted
to in some instances, it must be regarded rather as the
exception than the rule. Some of these cases possess
great interest from a theoretic point of view.

— 5° —

The Hyste7-ical Cough. — Among the local manifes-
tations of hysteria, to which more or less extended
reference has already been made, there remains to be
enumerated the phenomenon known as the hysterical
cough. It consists in a succession of explosions of
air through the glottis, of such rapidity as to cause
the impression that the cough is continuous. These
paroxysms of coughing are rhythmical in character,
and at the same time wholly unaccompanied by ex-
pectoration. There is no dyspnoea during the interval;
respiration is somewhat less profound than usual, and
physical examination of the chest yields only negative
results.

As a rule the character of the cough is hard and
dry; but in its more complex manifestations it is some-
times accompanied by aphony and vomiting.

The hysterical cough is a chronic affection, re-
markable for its tenacity, persisting for months and
even for years. It is, moreov.er, more or less exempt
according to Lasegue, from the influences arising from
menstruation and other intercurrent events of physio-
logical consequence. The results of treatment are,
as a rule, by no means flattering, and recovery usu-
ally takes place suddenly and without warning, or by
slow and almost imperceptible degrees. In whatever
manner recovery takes place there can be no cer-
tainty that the restoration to health is permanent,
since relapses are of frequent occurrence.

The affection is confined to women, and has al-

— 51 —

most always been observed before the age of five
and twenty.*

According to Lasegue it is peculiar to no par-
ticular form of hysteria, though Sydenham is of a con-
trary opinion, f

When the origin of the attack is traceable to a
simple cold, the subjects usually exhibit no particular
predisposition to catarrhal or pulmonary affections.
Upon close inquirj^, however, most cases of the kind
disclose the histories of previous hysterical attacks,
or at all events there is evidence of strong neurotic
tendencies.

During the persistence of the cough the appetite
is diminished and the digestive functions may suffer
more or less. There may also be a considerable loss
of flesh. But whatever the general symptoms ob-
served, the latter are rarely of sufficient gravity to
justify the anticipation of a fatal termination. With-
out entering upon the details of the subject further,
I will cite a case or two from my own practice and
that of others. The following extraordinary case of
hysterical cough is reported by Dr. Hartley:| " In

* " De la Toux Hysterique," by Dr. Ch. Lasegue,
Archives Generales de Medicine, 1854, vol. I, p. 513.

f Op. cit., p. 517.

X Extraordinary case of spasmodic cough in a girl aged
fourteen years. Recovery under the influence of valerianate of
zinc and the cold douche. The Medical Times and Gazette,
vol. II., p. 116.

— 52 —

the end of January last Rebecca D., a tolerably well-
developed, dark-complexioned girl of fourteen years
of age, came under the care of Dr. Hartle)'-, at Uni-
versity College Hospital, complaining of weakness,
loss of appetite, and suppression of the menses. She
had menstruated regularly two or three times, and
then ceased to do so during the three months prior to
her appearance at the hospital. Tonics, both mineral
and vegetable, were administered, and the girl went
on improving until March 31, when the mother
brought her back to the hospital, saying that four-
teen days previously she had been seized with a
cough, which gradually got worse, until it became al-
most incessant. In fact, according to the mother's
account, the girl never ceased coughing from the
time she rose in the morning till the time she went to
bed at night. While standing in the waiting room the
patient coughed incessantly, and as she was a highly
hysterical girl she was kept there for nearly an hour,
in order to try and tire her out. But at the end of
the hour she was just as bad as when she entered
the room. It was one continual round of short barks
(she did not give herself time to fill the lungs com-
pletely in order to be able to give a proper cough),
with no perceptible interval even for respiratory pur-
poses. The mother declared that she could not take
food. On being scolded and ordered to cease cough-
ing, she burst into tears; but the cough went on.
The patient answered questions hurriedly, and while

doing 50 she did not cough, but with the last words
the cough recommenced. After a time it was found
that she could control the cough by an effort of the
will, but only for a few seconds. There was no
chest affection, and no apparent disease of the throat
or fauces. The cough seemed to be entirely spas-
modic-Iaryngeal and the result of hysteria. One of
the students counted at inter^-als the frequency of
the cough, and without the patient's knowledge, and
it was found that she coughed at the regular rate
of seventy per minute, or four thousand two hund-
red times per hour. And reckoning that the girl
coughed during twelve hours out of the twenty-four,
if the mother, an intelligent and not at all enthu-
siastic female, was to be believed, the girl coughed
more than that— she must have coughed the enor-
mous number of fifty thousand four hundred times
daily (5 0,400). A mixture containing the valerianate
of zinc, the tincture of asafoetida, and camphor was
ordered to be taken three times a day, and a cold
douche with frictions to the spine to be applied night
and morning. On April 7 the patient was again
brought to Dr. Hartley, and the mother with evident
satisfaction stated that the cough had gradually
ceased three days after the commencement of the
treatment, and now the patient only coughed once or
twice a dav. On questioning the mother closely she
stated positively that the girl had coughed incessantly,
except when she was in bed (it ceased immediately on

— 54 —

lying down), during eight days, and that the cough
was just as frequent at home as it was while the
patient was in the hospital. So that if we even
reckon seventy per minute, and for only nine hours a
day, during the eight days she would still have cough-
ed the almost fabulous number of 302,400 times. As
the treatment related had proved so successful, it was
continued for a fortnight, and then changed to quassia
and iron.

The catamenia reappeared on May 19, and from
that time the girl went on improving until June 2,
when she was dismissed as cured.

The following case came under my observation
some years since, while serving a portion of my
medical apprenticeship as resident physician to the
Hudson River State Hospital for the Insane:

A. C, a girl aged nineteen years, of nervous tem-
perament, was committed to the hospital on account
of several mild attacks of what was evidently subacute
maniacal excitement. The cause of the last attack
was a severe fright caused by threats, on the part of
her mother, of sending her to jail if she did not "stop
her everlasting coughing."

Upon entrance into the hospital, and while I was
endeavoring to record the principal points in her case,
she coughed so incessantly and loudly that I was
obliged to have her conducted to a remote female
ward. On the following day, I learned, upon inquiry,
from the attendant that she was menstruating co-

— 55 —
piously, and that she was suffering acutely from dys-
menorrhoea. Her conduct was mischievous in the ex-
treme; she called out the window to the patients en-
gaged in work upon the farm, and addressed them as
angels; she tore the aprons and other articles of ap-
parel from the persons of the female patients about
her, and then ran away laughing and crying in a most
hysterical manner. After every explosion of this kind
she was seized with violent and continuous coughing,
which lasted for two or three hours.

After she had remained in the hospital for some
months, it was found that these attacks of coughing
invariably began a short time before menstruation and
continued until a day or two after the subsidence of
the same.*

Examination of the chest and larynx yielded ab-
solutely negative results.

What eventually became of this patient I am un-
able to state. She was removed from the hospital up-
on the subsidence of the mental symptoms; but the at-
tacks of coughing remained unaffected up to the time
of her departure.

The attacks ceased completely during sleep in
this case, a point upon which great stress is placed by
some diagnosticians.

*The connection between the menses and the cough is
apparently contrary to the experiences of Lasegue and others;
though I am convinced from this case of its existence, at least
in some cases.

_ 56 -

Dr. Synclair* presents the following case as an
instance of the " acute " forms of hysterical cough:

A young girl of eighteen years, having had sev-
eral attacks of hysteria, complained of rheumatic pains
and headache without febrile disturbances. Fifty
drops of laudanum mixed with a little water were
prescribed for her. On the 2 2d of October, immedi-
ately after the administration of the medicine, the pa-
tient was seized with a continuous cough. There was
no dyspnoea, no febrile movement and no pain about
the throat. At night, while asleep, the cough ceased
altogether, but only to return the following morning
upon awaking. Thus matters continued in spite of
treatment until the fourth day, when the cough sud-
denly disappeared to return no more.

This case does not appear sufficient to establish
the existence of an acute variety of the affection, and
I therefore cite it merely on account of the intrmsic
interest which attaches to the case, and entirely irre-
spective of any theoretic significance which it may
possibly possess.

* Edinburg Medical and Surgical Journal, 1825.

CHAPTER VII.

THE HYSTERICAL PAROXYSM.

The Hysterical Paroxsym. — By hysterical attacks
are commonly understood certain general tonic and
clonic convulsions associated with peculiar psychical
manifestations.

It is impossible to give a description of these at-
tacks of sufficient breadth to cover the manifold varia-
tions of which they are capable, and we shall therefore
confine ourselves to a delineation of the more salient
features, trusting to the resources of individual ex-
perience to fill in the details of the picture.

In the milder forms of the attack there are
rhythmical clonic spasms of the extremities, while at
the same time respiration is accelerated, irregular, or
interrupted. Consciousness, however, is not abolished,
since the subject gives evidence of understanding
what is said in her immediate neighborhood, and is
also able to exercise a certain amount of control over
her movements. The duration of an attack of this
kind is usually brief, rarely lasting more than a few
minutes. Sometimes, however, the primary attack is
followed by a rapidly occurring series of others, and
we have a somewhat analogous condition to that
which is present in certain forms of epilepsy. The
course of the attack is, however, by no means always

— 5» —

so benignant in character as the foregoing description
would indicate. In the more severe forms of the
seizure, consciousness is completely lost; the convul-
sions become tetanic, the trunk and extremities be-
come fixed and variously distorted; there is frothing
at the mouth and the respiration becomes slow and
stertorous. The convulsions, which were alternately
tonic and clonic in character, resemble so closely those
of true epilepsy that the seizure cannot be dis-
tinguished from the latter. This close resemblance
has gained for these paroxysms the designation of
^'' Hystero- Epilepsy,'' a title which has found favor
among recent medical writers of France where a vast
literature upon the subject has made its appearance.

Previous to the attack, and indeed throughout
the interparoxysmal period, the hystero-epileptic sub-
jects complain of the most varied hysterical symptoms.
Hemiangesthesia and hyperaesthesia of the ovaries
are among the most constant symptoms observed.

The paroxysm itself is usually preceded by an
aura emanating from the affected ovary and proceed-
ing in an upward direction. When the aura has at-
tained the upper portion of the trunk, the subject utters
the loud and piercing cry peculiar to epileptics, and
falls to the ground in an insensible condition. Tetani-
form spasms of the muscles now makes their appear-
ance. The muscles of the neck, trunk, upper and
lower extremities, are rigid; respiration is labored and
infrequent; the mouth is bedecked with foam, and the

— 59 —
tongue is protruded between the teeth, lending a re-
pulsive appearance to the countenance.

Upon the stage of tetanic muscular contraction,
there succeeds a period of complete muscular relaxa-
tion, during the continuance of which the breathing
is stertorous and the mental condition one of coma.
Soon, however, the exaggerated muscular phenomena
again make their appearance, this time in the form of
violent interrupted contractions, which give rise to the
most varied distortions. The body is bent violently
backwards and maintained in an opisthotonotic
position; or it may be rigidly extended, while the
limbs are flexed or extended, or it may be bent for-
wards or laterally (pleurosthotonos). Sometimes the
subject executes gesticulations of an evident purposive
nature, which, though in some cases characterized by
violence, are quite as often devoid of all injurious in-
tent, and recall forcibly the antics of a harlequin. At
such times the patient endeavors to stand upon her
head, turns somersaults, or bows with mock gravity to
those about her.

By degrees the purposive character of these ges-
tures become more pronounced, and at the same time
the emotional element enters more and more into their
composition. In the beginning of this stage of the
attack,^ the patient, as a rule, assumes attitudes of a
threatening character. The brows are contracted;
the lips are compressed and the whole facial expres-
sion is one of rage and resentment. Sometimes the

— 6o —

subject suddenly starts from a recumbent posture, and
clenches her fists, at the same time fixing a look of
defiance upon some unseen enemy. After the lapse
of a few moments, however, the attitude of anger is
succeeded by one of profound apprehension, which is
of short duration and is in turn followed by an ex-
pression of countenance indicative of the most beatific
hallucinations. The expression of beatitude gradually
passess into one indicative of extreme voluptuousness,
and is accompanied or succeeded by movements of a
correspondingly lascivious nature. This stage is fol-
lowed by a mental condition resembling somewhat
that of delirium tremens. She sees frogs, mice, ser-
pents, rats, and other offensive creatures which causes
her to cry out with apprehension, while at the same
time her countenance presents a frightful picture of
mingled fear and disgust.

By degrees the terrible hallucinations which lie
at the root of these phenomena subside; the face of
the subject wears an expression of contrition, and with
clasped hands she begs for clemency. From this
period recovery is rapid. The subject has alternate
fits of weeping and hysterical loquacity, during which
she upbraids those about her for being the cause of
all her distress.

It is very easy to provoke an attack resembling
that above described, in a person afflicted with hystero-
epilepsy. Thus, the sudden pinching of the skin in
the neighborhood of the inguinal region and about
the breasts is sufficient to cause a seizure.

— 6i —

Attacks of hystero-epilepsy are much less frequent
in this country than abroad, and when they do occur,
the phenomena presented are usually greatly modified.
Of the causation and pathology of hystero-epilepsy
little of a specific nature can be added; the most that
we can do so far as active interference is concerned,
is to utilize what is known concerning the mechanism
of the epileptic seizure, and to make due allowance
for the hysterical elements of the picture.

CHAPTER VIII.

HYSTERIA IN CHILDREN— HYSTERIA IN MEN.

Hysteria in Children. — As we have already had
occasion to observe, when considering the etiology of
the affection, hysteria may occur in girls and boys
under ten years of age; but the disease is far more
frequent about the time of puberty. In very young
girls the appearance of the disease is characterized by
alternate laughter and weeping, as well as extreme
mental irritability and intellectual inertia. The symp-
toms manifested by many boys at the time of puberty
are analogous in their general characteristics. Besides
the mental phenomena, however, the young boys thus
affected execute the most extraordinary gestures and
gymnastics. They stand upon their heads, creep
about the floor, uttering cries in imitation of various
animals, and otherwise misdemean themselves. Mas-
turbation is also common in both sexes at this time.
The following cases reported by Dr. William Roberts*
are good illustrations of hysteria in boys:

*" Cases of Hysteria in Boys," by William Roberts,
M. D. A paper read before the Manchester Medical Society,
"The Practitioner," 1879, vol. xxiii, p. 339, et seq. Vide: also
"Cases of Malingering," communicated by Mr. H. T. Batlin,
Registrar of the Hospital for Sick Children, London, 1871.
"On Hysteria in Children," by Dr. H. Paris, Journal de
Therapeutique, May lo, 1880; also London Medical Record, viii,
p. 232.

_ 63 -

Case I. — "The first example of hysteria in boys
that arrested my attention was the son of a merchant
in this town, whom I saw in 1870, This boy at the
age of thirteen, and as a sequence to some trifling ail-
ment, began to show hypochondriacal symptoms. He
became depressed in spirits, and dyspeptic, and suf-
fered from various undefinable ailments. Eight
months later a dry cough set in, which soon assumed
the character of the true hysterical bark. I was con-
sulted some four months after this began. The bark
had now degenerated into a hoarse sound, resembling
the bleating of a goat. The boy persisted for many
months in uttering this horrible noise oil day long,
almost without cessation, except during the hours of
sleep. At one time, for about four months, the symp- .
toms exhibited a curious diurnal periodicity. As soon
as the boy awoke in the morning he began to bleat
every two or three minutes, and continue to do so for
about three hours, and then cease; but precisely at
eight o'clock in the evening, with the regularity of
clock work, he began to bleat again, and continued to
do so until he went to bed and fell asleep. These
symptoms went on altogether for about fifteen months,
and then gradually subsided. Since then this boy has
grown into a fine, strong young man. There could
be no doubt as to the hysterical nature of the symp-
toms in this case. The patient was seen by Gendrin,
of Paris, and by Sir William Gull, both of whom pro-
nounced the case to be one of pure hysteria. An

— 64 —

interesting episode occurred during the progress of
the case. The boy was separated a good deal from
his brothers and sisters during the continuance of his
ailment, but on one occasion he passed some days in
the society of his elder brother. Some four months
afterwards this brother had an attack of hysterical
barking, which lasted a fortnight and then passed off.
A sister also was subsequently seized with similar
symptoms. She was nine years of age when her
second brother — the subject of this history — was suf-
fering from the above-described bleating. When she
reached the age of fifteen, four years after her broth-
er's recovery, she began to "bark" and show other
signs of hysteria. In her case the bark became a sort
of hoarse growl, which continued almost without inter-
ruption for nearly three years, and then slowly passed
away. In this family the hysterical bias was distinctly
inherited from the mother, who, in her youth, dis-
played severe hysterical symptoms of the classical
type." The subjoined case quoted from the same
authority is an illustration of the fact that hysteria is
sometimes developed during ths period of feebleness
which is associated with convalescence from an acute
disorder.

Case II. — '' The subject was a boy between eight
and nine years of age, whom I visited last year with
Dr. Mules, of Bowdoin. He was the second child of
a family of six. Dr. Mules informed me that three
weeks previous the boy was commencing to be conva-

- 65 -

lescent from a febrile attack of doubtful character,
when he was suddenly seized with paroxysms of loud,
passionate, tearless crying, with incoherent ravings of
a most alarming and distressing character. The par-
oxysms continued for a week almost without interrup-
tion. At the end of this week they suddenly ceased,
and the boy appeared almost quite well again. In a
few days, however, they recommenced, but not so
continuously. The paroxysms now lasted two or three
hours, and recurred three or four times a day. In the
intervals between them the boy appeared quite well,
eating and sleeping and amusing himself like a boy in
health. When I saw the patient he was in his bed-
room, looking calm and collected, with a soft, smiling
demeanor. Soon after we had descended into the sit-
tingroom to hold our consultation one of the parox-
ysms broke forth, and we heard the boy screaming.
We went up-stairs into his bed-room and found the
boy passionately crying and clinging to his mother, as
if in the extremity of terror. Nothing could pacify
him, and when we left the house the paroxysm was
still proceeding. To my mind the attack had an un-
equivocally hysterical complexion. What else could
it be ? The symptoms evidently concerned, and con-
cerned alone, the nervous system; and they resembled
those of no disease in the nosological category except
those of the chameleon of patholog}^, hysteria. As
these paroxysms had now persisted without ameliora-
tion for a period of three weeks, in spite of the resto-

6 z

— ae-
ration of the general health, we decided to send the
child away from home, in order to eliminate that most
fruitful of all promotors of hysterical manifestations,
home surroundings and sympathy. The interrupted
galvanic current was also directed to be applied daily.
Under this treatment the attacks became less and less
frequent, and finally, in about six weeks, ceased alto-
gether; and the boy has since remained in perfect
health. I must allow that the diagnosis in this case
was not so plain and undoubted as in the preceding,
but if any one doubts its correctness, I would ask him
this question: Suppose he saw these symptoms in a
young girl on the threshold of puberty, what would he
call the disorder?"

In the subsequent course of his paper. Dr.
Roberts reports cases which he considers to be in-
stances of hysterical contracture and " a clumsy imita-
tion of epilepsy." The ages of the subjects were eight
and eleven years respectively.

While I am not prepared to question the diag-
nosis in these last cases, I cannot help believing that
such instances must be comparatively rare, much less
frequent in fact than the variety of the affection ex-
emplified in the first two cases. Of that form of the
affection, which is characterized by uncouth noises,
alternate lachrymation, and spasmodic laughter, I
have seen several instances, as well as of that variety
of the disease in which the boys run about upon their
hands and knees, uttering barks and discordant

- 67 -

howls, or upsetting chairs and other articles of furni-
ture.

Hysteria inMenJ^' — It was formerly supposed that
hysteria was entirely confined to the female sex; but,
as we have already had occasion to remark, in the
course of this discussion, recent writers admit that the
affection is encountered in the male sex, though far
less frequently than among women. In many of the
so-called cases of hysteria, however, symptoms of
cerebral exhaustion are a far more prominent feature
than the purely hysterical manifestations; so that to
classify such cases as bona fide instances of hysteria
would be a manifest error. In all instances where
there is doubt as to whether we have to do with a case
of hypochondriasis, cerebral exhaustion, or cerebral
irritability, the best we can do is to classify the affec-
tion according to the characteristics of its most pre-
dominant symptoms. This is an axiom which, though
it fails perhaps to fulfill the most ideal theoretic exi-
gencies of the problem, will be found eminently useful
in practice. I have laid particular stress upon this
point in the classification of obscure functional affec-
tions of the nervous system in former publications.!

* See " A Case of Aggravated Hysteria occurring in a
Man," under the care of Dr. Todd. Recovery. The Medical
Times and Gazette, New Series, vol. vii., p. 242.

f " On the Nature of Nervousness," by J. Leonard Corn-
ing. The Medical Gazette, New York, Nov. 24, 1883. Also
" A Treatise on Brain Exhaustion," by J. Leonard Corning,
D. Appleton & Co., 1884, p. 116, et seq.

CHAPTER IX.

CAUSATION.— PATHOLOGY.— DIAGNOSIS.

Causation. — Hereditary influence constitutes an
important factor in the etiology of hysteria. The
affection is, moreover, far more common among
females than among males. This preponderance of
the disease among women is owing, in great measure,
to the increased development of the em^otional system
in the latter — a state of things which is greatly
fostered by the sensational nature of many features of
modern social life. But while sensational literature,
exaggerated drama, and the innumerable other ex-
travagancies of society undoubtedly play a prominent
part it the causation of the disease, it is equally cer-
certain that morbid states of the sexual apparatus are
not without etiological influence. Proof of the truth
of this proposition is seen in the extraordinary ex-
acerbation of symptoms, which takes place in hysterical
women at the period of menstruation, and in the fact
that the first indications of the disease are observed
in a large percentage of cases at the age of puberty.

General anaemia, hemorrhage, digestive derange-
ments, and in fact all causes which lower the nutri-
tion of the central nervous system may give rise to
hysteria.

All depressing emotions, such as conjugal jeal-

- 69 -

ousy, dread of pecuniary embarrassment, sudden
fear and protracted anxiety may induce the affection.

Contusions, even when of apparently trivial im-
port, may cause the disease in those of neurotic con-
stitution; and the concussion incident to railway and
other accidents may cause an outbreak of hysterical
symptoms in men and women alike.*

I have recently had under my care a gentleman
who met with a severe accident on the Long Branch
Railway, and in whom, in addition to other symptoms
of concussion, these hysterical symptoms were a
prominent feature. While sitting in my office he
would suddenly shed tears without the slightest ap-
parent provocation; but in an * equally short space of
time his weeping would be transformed into laughter.
When interrogated as to the cause of these manifesta-
tions, he could assign no reason, affirming in the most
emphatic manner that the weeping and laughter were
alike entirely involuntary.

Imitation is a powerful exciting cause of the dis-
ease in those of impressionable constitution; it is thus
that the " epidemics " of hysteria in recent and ancient
times are to be accounted for.

* Vide " On the Concussion on the Spine, Nervous Shock
and other Obscure Diseases of the Nervous System," by John
Eric Erichsen, F. R. S., etc.. New York, 1S82. Also, "In-
juries of Nerves and their Consequences," London, 1872. And
"Lectures on Diseases of the Nervous System," by F. E.
Anstie, The Lancet, vol. ii, 1872.

— -JO —

In a large percentage of cases hysteria makes its
appearance between the ages of fifteen and twenty-
one; though idle and vicious modes of living may
cause it to appear in children under ten years of age.

A factor of great importance in the causation of
the disease is masturbation, which is far more preval-
ent among girls than is commonly imagined. The
practice appears to be far more prolific of the disease
when indulged in by females than by males. I have,
however, seen two cases of the affection, both occur-
ring in men over thirty-five years of age, w^hich were
directly attributable to this vice.

Pathology. — Post-mortem examinations of the
nervous systems of hysterical persons have revealed
absolutely no lesion which may be considered as
characteristic of the affection. About all that we can
do is to submit the various symptoms of the affection
to analytical inspection, and thereupon construct as
consistent a theor}^ as we are able respecting their
origin. In this attempt the physiology of the nervous
system will certainly prove our most valuable guide.
Following this line of thought, it is evident in the first
place, that the greater part of the mental manifesta-
tions of the affection are to be regarded as the natural
outgrowth of the volitional paralysis and intellectual
torpor, which are such characteristic features of the
disease. For we find that, as soon as the will and the
purely intellectual faculties in hysterical persons are
developed by proper methods, the abnormally active

— 71 —

emotions are brought under subjection and there is
immediate mental improvement. The essential psy-
chological picture in hysteria is indeed but a complex
of riotous emotions. Again the spasmodic phenomena
of the affection may be accounted for by assuming an
inordinate explosiveness of certain motor areas of the
cortex, while the hypersesthetic manifestations are
easily accounted for if we admit a corresponding
irritability of the sensory districts.

On the other hand, abolition of irritability in cer-
tain motor fibres of the brain and cord might perhaps
account for the paralysis; while the anaesthetic symp-
toms might with equal propriety be ascribed to loss of
irritability in some portion of the sensory tract.

It is evident, therefore, from the foregoing, that
most of the phenomena of hysteria may be accounted
for, if we admit that in this affection cortical irrita-
bility is sometimes exaggerated and sometimes unduly
diminished or even totally suppressed.

I am fully aware that the foregoing theory is open
to criticism, but nevertheless, on the whole it appears
to be the most consistent which can be constructed in
the present state of knowledge. Jolly* has expressed
views with regard to the pathology of the affection,
which agree in many respects with those above
enunciated; and the same may be said of the theory
elaborated by Ross.f

*Op. cit., p. ^qoetseq.
t Op. cit., p. 862.

— 72 —

All theories which seek to explain the phenomena
of the disease on the assumption of changes in the
peripheral nerves are so manifestly inadequate that
they require no discussion.

Diagnosis. — Much might be and has been said re-
garding the various rules to be observed for the pur-
pose of differentiating hysteria from the host of dis-
eases which it simulates. Many of those axioms are,
however, far from infallible, as most physicians of
large experience can testify. We shall, therefore, ab-
stain from treading the quicksands of these logical
mazes, and shall content ourselves instead with a few
practical suggestions of more or less universal applica-
bility.

The most weighty diagnostic evidence of hysteria
is unquestionably afforded by the characteristic psy-
chical conduct of the patient. If the patient develop
extreme mental irritability in the absence of all excit-
ing causes from without, if she has lost volitional con-
trol, if her intellectual faculties are devoid of vigor, if
she is morbidly hilarious and lachrymose by turns, if
she evinces an abnormal and continuous craving for
sympathy, and if she resorts to various modes of de-
ception to obtain the latter, we may be reasonably
sure that we have to do with a case of hysteria.

The certainty of diagnosis is, moreover, greatly
enhanced if, in addition to the foregoing, globus and
some of the characteristic sensory and motor derange-
ments are present.

— 73 —

When the local manifestations of the disease are
the prominent feature, the most careful physical ex-
amination of the affected part should be undertaken
in conjunction with the general investigation. We
have already alluded to this point when discussing
hysterical joint affections.

The determination of the true nature of an hys-
terical attack is usually simple in uncomplicated cases,
especially if the previous history of the patient be ac-
cessible. In the more complex phases of the disease,
however, it is often impossible, to differentiate the at-
tack from the seizure of true epilepsy. This point has
been discussed under the head of hystero-epilepsy.

Hysteria is indeed a dexterous counterfeiter of
other diseases, but, like most dissemblers, her falsifica-
tions will not stand the test of analysis.

CHAPTER X.

PROGNOSIS— TREATMENT. •

Prognosis. — In cases of long duration, with a pre-
vious neurotic history, the prospects of recovery are
decidedly unfavorable; this is especially so when the
psychical disturbances are persistent and permanent in
character. On the other hand, even violent transitory
mental disturbances are not necessarily of bad omen
as regards eventual recovery from the purely hysterical
symptoms; but it is unfortunately true that these
attacks of insanity are liable to leave an ineffaceable
trace behind in the form of psychical weakness, and
even complete dementation.

When the disease is of short duration and the
result of psychical infection (by imitation) the prog-
nosis is favorable, provided that the subject can be
properly isolated and placed under appropriate treat-
ment.

Again, when manifest physical debility is the
demonstrable cause of the disease, reinvigoration by
forced feeding and rest often yields suprising results.
It must be admitted, however, that the danger of re-
lapse is always more or less great, unless the subject
can be properly protected from the ill-directed sym-
pathy of over-zealous friends.

Fore-warned is, however, fore-armed, and if the

— 75 —
physician, realizing his personal responsibility in the
case, presents a true picture of the possible dangers
of excessive sympathy to the friends and family of
the patient, much future difficulty and annoyance may
be avoided.

Treatment. — The proper management of hysteri-
cal cases is one of the most complicated problems in
the whole range of medicine. In the first place, owing
to the imitative qualities of the affection, the conscien-
tious practitioner has much difficulty to persuade him
self that he is really confronted by a true pathological
condition, and that he is not the victim of deception
pure and simple. The fact that hysterical women are,
of all others, most prone to prevarication of all kinds,
lends force to his scepticism. As a result of this un-
certainty of mind the efforts of the attending physician
are characterized by a perfunctory observance which
is apt to dispel the confidence of patients and friends
alike. It is therefore necessary, above all things, to
evoke confidence on the part of the patient. This is
best accomplished by the adoption of a manner ex-
pressive of firmness, but not necessarily devoid of
feeling. Above all things, anything approaching ex-
aggeration of manner should be carefully avoided. If
the physician be called during the progress of an
hysterical attack, he should avoid alarming the friends
of the patient by abrupt or unnecessarily harsh injunc-
tions. A very good mode of procedure is as follows:

Cause the patient to be held firmly by those pres-

- 76 -

ent, in such a manner that she is prevented from
throwing herself about in a violent and aimless man-
ner. Then, having loosened her clothing, particularly
about the throat and neck, cold water may be dashed
upon the face until there is undoubted evidence that
the paroxysm is over. This is an old but effective ex-
pedient. Again, a towel may be dipped in cold water
and the face of the patient submitted to a species of
mild flagellation. Or, the nose and mouth of the
patient may be held closed so as to interrupt breath-
ing— a very effective method of bringing the attack to
a speedy termination. Should a faradic battery be at
hand the patient may be treated with the wire brush.
Care should be observed, however, not to employ cur-
rents of too great intensity. Carter has laid down the
following rules for treating the attack:

" The attacks will, in all probability, occur during
d meal, or when there are strangers present, or at some
inconvenient time and .place, and it may on this ac-
count be necessary to have the patient removed to her
bedroom. In such case she should be carried there
as quickly as possible, placed upon the floor, and im-
mediately left quite alone, the door being shut, and
no one being suffered to open it on any pretext what-
ever until the patient does so herself. But if the room
in which the attack takes place can be spared for a few
hours, it should be cleared and shut up in the same
manner, and in either case especial care must be
taken not to give utterence to a single expres-

— 77 —
sion either of sympathy or alarm. After the lapse
of a longer or shorter time, often at a meal, and
sometimes not until the next morning, she will
present herself as usual, and will perhaps offer some
apology, or express some regret for her illness. This
should be graciously received; and then every attempt
on her part to return to the subject must be carefully
and industriously foiled, no inquiries being made
about her health, and all complaints being interrupted
by the introduction of ordinary conversational topics."

The inhalation of chloroform has been proposed
with a view to aborting the attack, and in severe cases
some excellent results have been reported. Hypoder-
mic injections of morphia and injections of opium
have also been advocated for the same purpose. Ex-
cept, however, in very severe attacks, these potent
remedies should be discarded in favor of the more
simple and available means already referred to.

In France the hystero-epileptic phase of attack is
much more common than with us, and in this con-
dition Jolly has seen good results from large doses of
the bromide of potassium in this tetanic manifestation
of the affection.

In very rare cases there is a spasm of the glottis,
during the attack, of sufficient intensity to cause grave
apprehension. Under these circumstances a sponge
saturated with chloroform or ether may be held over
the mouth and nose of the patient; or, the physician
may pass his finger below the eppiglottis and draw it

- 78 -

upwards. The latter expedient will, however, rarely
be required. So much, then, for the hysterical seizure.

But what of the fully developed disease; what
shall we do to overcome the multiform manifestations
of the hysterical state ? To begin with the state of
the patient in general, we must endeavor to ascertain
some peccant physiological feature which will, in a
measure, account, or at all events tend to perpetuate,
the unstable condition of the central nervous sys-
tem. Undoubtedly a most common feature of this
sort is general anaemia. The best method of combat-
ing this state of bloodlessness when it exists in a
hysterical person is by appropriate tonics, and, above
all things, by feeding and passive exercise. Should
there be an inordinate accumulation of fat as well as
lack of blood, we should prescribe massage, general
faradization, and plenty of fresh air. Weir Mitchell
has, perhaps, understood these matters as well as any
recent medical writer. To the medical man who is
unacquainted with this gifted writer's contributions
to the subject of physiological alimentation, there
remains for exploration fascinating chapters in scien-
tific literature.

States of plethora are far more rare in hysteria
than those of sanguineous impoverishment. A failure
to recognize this fact led among the older physicians
to an incredible amount of blood-letting and other de-
pleting measures. As a consequence of such mistaken
treatment, many hysterical persons were doubtless

— 79 —
forced into a condition of premature decline, in which
the outcome was not infrequently fatal to life itself.
In the eyes of modern physiology all this seems in-
credible enough, and it must indeed be conceded that,
if we have not arrived at perfection, we are, at least,
far ahead of the preceding generation of physicians in
the management of many phases of hysteria.

The relation of affections of the genital organs
to hysterical symptoms is a question which is liable to
be presented to every practitioner who is brought
■ much in contact with the manifold neuroses which
constitute such a baneful feature of the lives of women
residing in great cities.

Most authors who have written on hysteria are
accustomed to devote much space and ingenuity to a
discussion of this interesting conjunction of symptoms.
To me all this seems a useless waste of energy. In
the first place, I have seen many women suffering
from hysterical symptoms, in whom the reposition of
a displaced uterus, or the sewing up of a lacerated
cervix brought no relief so far as the neurotic manifes-
tations were concerned. On the other hand, I have seen
such persons improve in a most wonderful way under
treatment by hyper-nutrition, massage, Franklinization,
and appropriate moral restraint. By moral restraint I
mean removing the patient from the vicinity of friends
and family, so that there is no danger of subjecting
the patient to the highly prejudicial influence of ill-
advised sympathy.

— 8o —

Among the remedies which have been largely em-
ployed by physicians in former times in the treatment
of hysteria, I would mention galbanumand asafoetida.
Since, however, modern physiological research has
made itself more generally felt in practice, the tend-
ency to rely upon the specific action of remedies of all
kinds has grown progressively less. This applies with
particular force to hysteria, where, as we have seen,
general hygienic measures are asserting themselves
more and more. Among the therapeutic measures of
most uniformly good effect is the cold douche or
sponge bath. It may be employed where there is an
absence of manifest debility, and should always be im-
mediately followed by vigorous frictions.

The anaesthetic manifestations of hysteria may be
treated with advantage by daily applications of Farad-
ism, or, still better, Franklinism. The application of
metals, magnets, and the like, as recommended by
certain French physicians, has no other advantage
than the appeal which such devices inevitably make
to the titanic imaginative powers of the patient. To
me there is a kind of mediaeval quackery about such
expedients, which has given rise to a feeling of repug-
nance that I am quite unable to overcome. I am quite
willing to thus avow my scepticism in the presence of
the general alchemistic state of the whole quuestion of
metallotherapy.

Narcotics and even ansesthetics may be resorted
to in combating the hyperaesthesia and neuralgia

which are such a tormenting comphcation of many
hysterical cases.

As to the hysterical headaches frequently met
with, bromo-caffein, inhalation of the nitrite of amyl,
the bromides, and chloral, in considerable doses, will
be found useful.

Where paralytic complications are a marked fea-
ture, electricity, particularly the static and faradic
varieties, should be persistently and systematically
employed. On the other hand, when we have to do
with spasms, as for instance in persistent globus^ the
constant galvanic current may be employed with ad-
vantage. Alternate hot and cold applications also
frequently render good service. When the spasm is
limited to the stomach syphonage with hot water may
be resorted to, provided that the introduction of the
tube is attainable without too much nervous shock
to the patient. In order to facilitate the entrance of
the tube into the larynx, and to prevent spasm in the
latter, I have found the painting of the pharynx with
cocaine, and the projection of a fine spray of a strong
solution of the latter into the upper air passages, an
excellent expedient.

When there is spastic or paralytic retention of
urine, no hesitancy should be exhibited, the catheter
being at once called into requisition. In spraying the
upper air passages, as above described, I have inci-
dentally observed that a severe attack of globus may
sometimes be arrested in this manner. This, then, is

— 82 —

a brief sketch of the resources at our disposal in the
treatment of this most paradoxical, aggravating, ob-
stinate, and obscure neurosis.

As a matter of course the thousand and one little
exigencies liable to arise in the course of protracted
treatment cannot be separately treated in a work of
this kind. Enough that we have given an outline of
the policy to be pursued in the treatment of the cases
most commonly met with. After all has been said
which can reasonably be said, it must in truth be ad-
mitted that the personal ascendency which the physi-
cian is able to gain over his patient must ever consti-
tute one of the most important, if not the supremely
important, factor of successful treatment.

EPILEPSY.

CHAPTER I.

CLASSIFICATION.— SYMPTOMATOLOGY. — SYMP-
TOMS WHICH IMMEDIATELY PRECEDE
THE ATTACK.— AUR/E EPILEPTIC/E.

In its typical manifestations epilepsy is charac-
terized by phenomena indicative of disordered sensa-
tion, motion, and intelHgence. These derangements
succeed each other in the severe forms of the disease
simultaneously and suddenly; in the milder cases in
a certain rhythmical succession, where, as in the
least grave variety, only one class of symptoms is
represented.

It is customary to divide the phenomena of the
disease, according to the nature of the paroxysm, into
epilepsia gravior or grand mal, and epilepsia mitior or
petit mal. Besides these principal divisions, which
serve to denominate the more extreme and obvious
forms of the disease, recent writers have recognized
certain transitional and irregular varieties of the affec-
tion, which, in their turn, have received a classification,
albeit more or less arbitrary.

In the following description we shall consider

— 84 —

the phenomena of the paroxysm under these head-
ings:

1. Grand mal, that variety of the affection in
which the seizure is characterized by coma and gen-
eral convulsions.

2. Petit mal, that form of the disease in which
the paroxysm is alone characterized by loss of con-
sciousness, the convulsive condition of the voluntary
muscles being absent.

3. Epilepsy characterized by partial impairment
of consciousness and circumscribed muscular spasms.
This group constitutes a connecting link between the
first two varieties of the disorder.

4. Irregular forms of the attack.
Symptoffiatology . — We may divide the symptoms of

epilepsy into (i) such as precede the paroxysm, (2)
such as occur during the paroxysm, and (3) such as
are observable during the intervals of the attacks. In
the following description we shall follow in many re-
spects the admirable classification of the phenomena
of the disease adopted by Nothnagel, a writer whose
clear clinical insight is only equaled by his masterly
experimental researches upon the pathology of this
most interesting disorder.

-Premonitory Syjfiptoms. — These may be divided
into such as give warning of an impending attack some
hours or days before its occurrence, and such as im-
mediately precede the seizure — the so-called mim
epilepticce. The distant premonitions usually assume

- 85 -

the character of mental disturbances in the form of
irritability, loss of memory, confusion of ideas, and
unusual depression or exaltation, vertigo, and head
pains.

Symptoms ivhich immediately precede the Attack:
Attrce EpilepticcB. — The aura may affect the sensory,
vaso-motor, secretory, motor, and psychical functions.

In a considerable proportion of cases the subject
is able to give from memory an account of the aura
which preceded the attack. Sometimes, however, con-
sciousness is affected so suddenly that the patient re-
tains but a shadowy recollection of the occurrences
which immediately preceded the seizure.

The immediate prodromes occur more frequently
and exhibit greater variety than the remote warnings;
indeed they possess such multifarious characteristics
that any attempt at exhaustive enumeration of the
phenomena would necessarily be at once imperfect
and unnecessary.

In the following description, therefore, we shall
simply aim at giving a general account of the charac-
teristics of these premonitory symptoms, trusting to
the individual experience of the reader to amplify
his acquaintance with this interesting class of mani-
festations.

The setisory aura consists in tickling sensations,
or burning, lacerating pains, which usually begin at
the extremity of a limb, in the toes and fingers, and
extend upward toward the breast and head. Some-

— 86 —

times, on the contrary, a loss of sensation is experi-
enced in circumscribed localities, such as a portion of
a limb, or one side of the face. This diminution of
sensibility may often be recognized by the aid of the
sesthesiometer, or by thermic tests. Again, in a certain
percentage of cases, the subject complains of isolated
pains in the head, either at the vertex or upon one side
of the cranium.

Vaso-motor disturbances manifest themselves by
sudden redness or pallor of the affected localities.
These circulatory disturbances are, moreover, often
preceded by sensations of burning, numbness, or by a
chill, which, beginning in the fingers and toes, creeps
up the spine toward the head and shoulders.

Acting upon the observation that in certain cases
the vaso-motor prodromes assume an unusual degree
of prominence, recent authors have sought to dis-
tinguish a separate variety of the affection, the so-
called epilepsia vasomotoria. There is evidently, never-
theless, but scant justifications for such a classification,
inasmuch as, if we recognize an epilepsia vasomotoria,
we are equally compelled to distinguish a large number
of sub-varieties of the affection, according to whether
the prodromes are characterized by a predominance
of this or that special symptom. It is evidently more
logical, therefore, to abstain from attempting to estab-
lish further subdivisions of the disease on the score
of any mere peculiarity of the aura.

The vertigo and faintness often observed as a

— 87 -

forerunner of the paroxysm are, doubtless, attri-
butable to disturbances of the vaso-motor condi-
tions of the cerebral circulation, and not, as some
authors maintain, to dilatation of the abdominal
vessels.

The secretory aura manifests itself in an inordinate
secretion of tears, perspiration, or saliva. Saliva-
tion is indeed often enough observed, whereas
unusual activity of the lachrymal glands is more
rarely met with. Nothnagel has frequently remarked
profuse perspiration as an immediate precursor of the
attack.

AurcB of the Special Senses. — The auras of hearing
consist of buzzing, roaring, barking, hissing, and ring-
ing. Sometimes sepulchral voices are heard calling
in a strange and unintelligible manner, or warning the
subject of impending doom. At times also low, musi-
cal sounds are heard, which may be gay or melancholy
in character. A patient of mine complained that im-
mediately before the attack he heard the notes of a
dirge, ''and then all was darkness."

Where the aurse are visual, the phenomena con-
sist in colors, flashes of light, and balls of fire. In
some cases the subject finds himself surrounded by
grotesques or awful shapes, which, with outstretched
claws, leer at and mock him. In yet other instances
he conceives himself to be in the midst of wild beasts,
or hideous reptiles, prepared at any moment to devour
him.

Aurse of the sense of smell are usually, though
not always, of a disagreeable character. In some
cases the patient declares that just previous to the at-
tack he is overwhelmed by the odor of dead animals
or cess-pools. Sometimes, however, pleasant odors,
such as the perfumes of flowers, are described.

The aurae of taste are characterized by various
forms of perversion. Sometimes the patient experi-
ences a salty or metallic taste; at others a sensation
of sweetness is noted, which causes him to smack his
lips with pleasure.*

The motor aura exhibits itself in various ways. In
a considerable percentage of cases, tonic, or more fre-
quently clonic, spasms are observed affecting certain
groups of muscles. Thus, one side of the face is fre-
quently affected by the spasmodic contractions, where-
as in others the spasm begins in the hand and ascends
to the face. Sometimes the muscles of the tongue are
involved, the subject becoming suddenly speechless.
In other cases, again, the muscles of the eyes are im-
plicated, giving rise to squint. These are the cases in
which the subjects complain of double vision.

Visceral Aurce. — These are exceedingly common
and consist of sensations of heat, cold, rumbling, or
straining which are usually referred to some organ
contained within the abdominal cavity. The so-called

* Frank, cited by Nothnagel, has recounted an instance
of this sort.

epigastric aura is a sensation referred by the patient
to the region of the stomach. The attack is also pre-
ceded in some cases by straining at stool and on
urinating.

The psychical aura is of frequent occurrence, and
may consist of an emotional disturbance manifesting
itself in fear or disgust, or in derangement of the intel-
lectual faculties assuming the form of confusion of
ideas. It is often very difficult to classify this cate-
gory of phenomena, for the reason that the description
given by the patient is so imperfect as to admit of no
certain conclusions. Thus, complaints are often made
of a strange indescribable sensation of confusion or
vacancy, which the patient recalls with evident diffi-
culty. These cerebral phenomena should always be
inquired after by the physician, as they constitute an
interesting and frequently observed type of premoni-
tory symptoms.

CHAPTER II.

THE MANIFESTATIONS OF THE EPILEPTIC PAR-
OXYSM—GRAND MAL

Epilepsia Gravior, or Grand Mai. — It is custom-
ary among most writers to divide the epileptic attack
into two or even three stages. During the first stage
of the attack the patient lies in an unconscious con-
dition, and his muscles are thrown into a state of
tonic spasm. Unconsciousness persists during the
second period of the paroxysm, and at the same time
the toxic contractions are succeeded by clonic con-
vulsions. The third period is characterized by cessa-
tion of the spasms and final restoration of conscious-
ness.

It will be well to consider somewhat more in de-
tail these various stages of the paroxysm.

First Stage. — As already noted, there is entire
loss of consciousness during this period of the seizure.
Sometimes the loss of volitional power is so sudden
that the subject falls to the ground, as if stricken by
some unseen power. At others, consciousness disap-
pears less rapidly and the patient is enabled to sink
upon a chair, lounge, or bed, thus avoideng the danger
of falling against some object which might cause him
serious injury. It has frequently happened, when the
loss of consciousness has been sudden, that patients

— 91 —

have fallen against a stove or even into the fire itself, and
have thus sustained frightful injuries. Owing to the pro-
found coma, they feel not even the remotest sensation
of pain, and are consequently unable to rescue them-
selves. When the patient has been under observa-
tion, great pallor of the face has been noted, which at-
tains a maximum degree of intensity at the moment
the subject sinks into unconsciousness. Some patients
utter the so-called epileptic cry immediately before
falling. This cry is of so strange and piercing a char-
acter that animals and men are frequently thrown into
a state of consternation upon hearing it. The feel-
ings aroused by this cry, when heard among the wards
of an insane asylum, are certainly anything but agree-
able, even to those long accustomed to the sound.
During or after the fall the muscular system is
thrown into a condition of tonic spasm. The dis-
tribution of the latter is subject to considerable varia-
tion. Sometimes there is opisthotonus; at others but
one half of the body is involved and curvature takes
place in a lateral direction. In severe cases the
spasm is general, involving the entire muscular sys-
tem. The muscles of mastication are violently con-
tracted, causing the jaws to close with such violence
as to break the teeth or produce severe laceration of
the tongue, should the latter chance to be implicated.
The most varied and hideous distortions are produced;
the pupils are dilated and fail to react to light; the
eyeballs are deviated and the head and neck are flexed

— 92 —

in a backward direction, or rotated when the action
of certain groups of muscles prevails over that of their
antagonists. The muscles of both the upper and
lower extremities are also involved. The forearm is
flexed or extended; the thumb and fingers are bent
into the palm; the lower extremities are violently ex-
tended and the foot is incurvated. The muscles of
the throat and those concerned in respiration are also
involved in the spasm, and breathing is arrested.
Reflex action is impaired or absent in many cases. As
already noted, the tonic contractions are not always so
universal as the foregoing description would imply,
and in some cases they involve certain groups of
muscles only. Nor does the paroxysm always begin
with tonic muscular contractions. Sometimes these
are wholly wanting, clonic spasms setting in at once.

Second Stage. — As already noted, the prominent
characteristics of this stage of the attack are the clonic
spasms, which set in in from two to forty-five seconds
after the inception of unconsciousness. With the advent
of the clonic convulsions a remarkable change takes
place in the appearance of the patient. The pallid
aspect of the face gives place to a dark, livid hue,
while at the same time the veins are seen to be
enormously distended. If the radial pulse is ex-
amined at this time, it will be found to be feeble
or quite imperceptible, though both carotids are
seen to pulsate violently. The majority of the mus-
cles of the head, trunk, and extremities are involved

— 93 —
in the convulsive seizure. Owing to the preponderant
action of certain groups of muscles over the corre-
sponding antagonists, the most remarkable postures
are produced. In a considerable number of cases,
one side of the body is seen to be more affected than
the other; and this is said to hold true even in those
cases where the convulsions are general.* Sometimes
the violence of the spasms is so great as to cause dis-
locations, fractures, and severe wounds of the head
and extremities. The teeth are violently ground to-
gether, and the tongue, becoming implicated, is
severely lacerated. In a large number of cases the
patient is seen to froth at the mouth, and the saliva
discharged is tinged with blood derived from wounds
of the tongue and raucous membrane of the mouth.
At the same time the contents of the seminal vesicles,
rectum, and bladder may be evacuated, the contents
of the latter being frequently ejected with great vio-
lence.

This stage of the attack usually lasts from two to
four minutes; in some instances, however, the clonic
spasms persist five or even ten minutes. The condi-
tion of the pupil is variable, being sometimes consid-
erably dilated, at others contracted.

Third Stage. — Usually a cessation of the convul-
sions is accomplished gradually, but in exceptional cases
the spasm ceases suddenly. The spasmodic contrac-

* Nothnagel.

— 94 —
tions grow less and less and finally disappear, respira-
tion is attended with less difficulty, the cyanotic
appearance of the face is sensibly diminished,the limbs
become relaxed, the pulse becomes stronger, and at
length consciousness is more or less completely re-
stored. Sometimes, however, the patient passes from
a condition of semi-consciousness into a deep sleep,
and does not awaken for hours.

Westphal f has arrived at the conclusion that an
elevation of temperature after the attack is rare.

Williams | found that the temperature might rise
as much as 3° F. after severe convulsions.

The accounts given by various authors as to
changes in the composition of the urine are conflict-
ing-i

After the paroxysm has subsided the subject
usually suffers from great physical exhaustion, mental
confusion, derangement of memory, and in rare in-
stances from paresis, or hemi-paresis.

f "Archiv. fiir Psychiatric und Nervenkrankheiten,"
vol. i.

X "Medical Times," 1867, vol. ii.

II Vide Ebstein, " Deutsches Archiv. fiir klinische Medi-
cin, vol. xi.

CHAPTER III.

THE MANIFESTATIONS OF THE EPILEPTIC PAR-
OXYSMS CONTINUED.— PETIT MAL.—
SEIZURES CHARACTERIZED BY
LOSS OF CONSCIOUSNESS
AND LOCAL SPASMS.

Epilepsia Mitioi' {Petit Mai). — This form of the
disease is characterized by transitory loss of conscious-
ness, unaccompanied by foaming at the mouth, pulsa-
tion of the carotids, marked cyanosis, or manifest
spasmodic contractions of the voluntary muscles.
Persons subject to attacks oi petit mat suddenly relin-
quish the employment in which they may happen to
be engaged, remain perfectly motionless for a few
seconds, and then resume their former occupation. If
engaged, for example, in speaking, such persons sud-
denly pause in the most unaccountable manner in the
middle of a sentence; but, after an interval of a few
seconds, conversation is again resumed. If walking
upon the street, they suddenly stop, but do not usually
fall, unless the period of unconsciousness should be
unusually long. In some instances, however, auto-
matic actions are not immediately interrupted, and the
patient continues the occupation in which he may
happen to be engaged. Thus, musicians have been
known to continue playing during an attack of petit

- 96 -

nial without the audience becoming in the sHghtest
degree cognizant of anything unusual in their conduct.

In the majority of cases the aurae are entirely
absent, or so slight in character as to escape the obser-
vation or recollection of the patient. The most com-
mon warnings consist in flashes of light, darkness
before the eyes, and dizziness. Numerous sensations,
already referred to as constituting aurse, may, it is
true, occur in the entire absence of true epilepsy. But,
when these symptoms occur with a certain periodicity,
and are accompanied, moreover, by mental confusion,
the suspicion of epilepsy is justified. The diagnosis
becomes doubly sure if at such times an involuntary
discharge of fasces and urine take place.

In a large number of cases no evil after-effects are
observed, and the patient remains entirely oblivious of
his previous condition. Sometimes, however, even
when the attack has been slight, symptoms are ob-
served which are apparently entirely out of proportion
to the magnitude of the exciting cause. The patient
becomes dull and sleepy, or suffers from headache,
depression or irritability. Memory is also more or less
impaired, especially for recent occurrences. These
symptoms often persist for several hours; but they do
not constitute the entire list of mental accidents to
which these apparently insignificant attacks of epilepsy
may give rise. Thus, the terrible disorder known as
epileptic mania is one of the most common results of
these mild attacks of epilepsy. To this point we shall
have occasion to refer hereafter.

« — 97 —

Epileptic Seizures Characterized by Loss of Consci-
ousness and Local Spasm; Transition Forms. — This vari-
ety of epilepsy constitutes a veritable connecting link
between the major and the minor forms of the affection.
In its general characteristics there is a pronounced re-
semblance to petit mal, with the addition, however, of
marked spasmodic phenomena. It rarely happens
that tonic and clonic spasms set in simultaneously, or
follow each other, as in grand mal. In the majority of
cases, on the contrary, but one or the other form of
spasm is found to exist. The location and extent of
the spasmodic phenomena are subject to considerable
variation, and to enumerate all the clinical possibilities
would be next to impossible. Sometimes the tongue
is rolled about from side to side, while the jaws are
alternately opened and shut, as in chewing. In some
patients, on the other hand, the attack manifests itself
merely by spasm of the facial muscles, strabismus, or
closure of the eyelids. Again, in a not inconsiderable
number of cases there may be movements of the lips,
violent contortions of the muscles of the face, local
spasms in the extremities, or more rarely in the trunk,
and (according to some writers) arrest of respiration,
owing to spasm of the respiratory muscles. Where
the spasm is located in the extremities there is rigidity
of the same, or some of the fingers or toes are ex-
tended or bent, or, where the convulsions are clonic in
character, the affected parts are moved backward and
forward, with a pendulum-like motion. Sometimes

— 98 — »

there are clonic and tonic spasms which are more
general in character, and which at first sight would
suggest the major form of epilepsy. But, as a matter
of course, an absolutely sharp demarkation between
the various forms is not always easily discernible, and
it is consequently necessary to bear in mind the rela-
tive value of this or, indeed any other classification.

It has been alleged by some writers that the loss
of consciousness is by no means absolute in this form
of the seizure. Nothnagel, on the other hand, is of
the opinion that in the great majority of cases an ar-
rest of consciousness takes place, which, although
often only very transient is still complete.

CHAPTER IV.

MASKED EPILEPSY.

Irregular Forms of the Attack [Larvated, or Mask-
ed, Epilepsy). — In this form of the disease the par-
ox5''sm is quite as well marked as in grand 7?ial, the
only difference being that, instead of the violent con-
vulsive movements of the latter, certain "automatic "
mental and motor phenomena are evolved, which,
though often apparently systematized, take place
while the subject is in a state of partial or entire un-
consciousness.

The following case, which occurred in my own
experience, is a good illustration of this phase of the
disease:

A. v., a young unmarried woman, aged twenty-
five years, was brought to my office about a year ago,
suffering, as her friends imagined, from the premoni-
tory symptoms of insanity. On inquiry, I learned
that the family history on both the father's and
mother's side was good so far as the existence of
mental trouble was concerned, and the only neuro-
pathic evidence discoverable was afforded by the girl
herself, who complained of being " nervous " and
"fidgety," and somewhat lacrymose and emotional at
times. These attacks, were, however, in no wise trace-
able to menstruation.

Upon examination, the organs of the thoracic and

abdominal cavities were found to be in a healthy con-
dition, and, having noted this fact in my case-book, I
was about continuing my examination of the patient,
when suddenly she arose and, without the slightest
warning, spat upon the floor, at the same time
dropping her muff, which she had been holding
in her hand. For an instant after this she stood
with an expression of indescribable horror, as if trans-
fixed, her face meanwhile wearing a chalky appear-
ance. In a moment, however, all was over, and she
resumed her seat, as if nothing unusual had happened.
The mother of the girl, who was present, began subse-
quently to reprimand her in the severest terms,
at the same time observing, with an expression of ex-
ultation: " There, you crazy, nasty thing, the doctor
has caught you now, and he will send you to an insane
asylum." Upon close questioning, the patient denied
in the most emphatic and convincing manner all
knowledge of what had occurred, and I am thoroughly
persuaded that she told the truth. From her mother
I learned that she had formerly had many similiar
attacks, during some of which she had shown a tend-
ency to destructiveness, breaking any object upon
which she chanced to lay her hands. Several orna-
ments and pieces of furniture had been destroyed in
this way, on account of which she had become very
unpopular in her family, the members of which would
gladly have seen her relegated to an asylum, as I soon
ascertained.

Sometimes the acts perpetrated by persons suffer-
ing from this masked type of epilepsy are far more
compUcated. I can recall a case illustrative of this
complex mental automatism, occurring in the family
of an intimate friend. The following are the principal
points of interest connected with this case:

C. E., a neurotic lad of eighteen, of delicate
frame, came under my observation some two years
since. The principal reason for consulting me, as his
father explained, was because the boy's " memory "
seemed to be affected, and because of certain other
mental traits which excited the apprehension of his
parents and teachers. On questioning the father of
the lad, I learned that the latter was in the habit of
running away from school and from his home, remain-
ing absent sometimes for days at a time. So annoy-
ing had these frequent occurrences become that the
parents of the boy had finally been induced to attach
a leathern placard to his coat bearing his address as
well as a request to the police to return him to his
home when found. Indeed, he had been returned by
the police on sundry occasions; but the most singular
part of the transaction was the fact that he denied in
the most obstinate manner all knowledge of his
singular peregrinations — a statement which he reso-
lutely maintained in the face of the severest chastise-
ment. This was the more remarkable since his
veracity upon all other topics was unquestioned. On
examining the lad, I found his back, ankles, and thighs

covered with scars, which upon inquiry I learned were
the result of inhuman beatings received at the hands
of his guardians, who considered him to be at once a
truant and a liar. With tears in his eyes he declared,
with the most convincing sincerity, that he had no re-
collection whatever of the occurrences for which he
had been punished.

Such cases as this are far more common than is
generally supposed, as doubtless most practitioners of
large experience can testify.

CHAPTER V.

"THALAMIC" EPILEPSY. — JACKSONIAN EPI-
LEPSY.—SENSORY EPILEPSY.

Under the designation of "Thalamic Epilepsy,"
Hammond* has published an interesting case, the chief
characteristics of which are " conscious hallucinations,
followed by unconsciousness, but unattended by mus-
cular spasm. This form of affection is comparatively
rare."

With regard to the frequency of the attack, in
common epilepsy the greatest variations are ^en-
countered. Thus, in some cases a year may elapse
without the appearance of a single paroxysm, while
in other cases the seizures may occur thrice or
even half a dozen times daily. Sometimes, again,
they exhibit a well-marked periodicity, whereas, in
not a few cases no kind of regularity is discern-
able. In yet another class of cases the subject has
hardly time to emerge from one convulsive attack
before he is beset by another, the paroxysms following
each other in such rapid succession that there is finally
no apparent restoration of consciousness between the
seizures. This condition is known as the status epilep-
ticus — a phase of the disease which has received con-
siderable attention from French writers, notably from

* "On Thalamic Epilepsy," "Archives of Scientific Med-
icine," August, 1880.

— I04 —

Bourneville.* This writer's subdivision of the condi-
tion seems to me, however, unnecessary. The main
points to bear in mind are that this form of the attack
is, generally speaking, of graver import than the
ordinary seizures, that hemiplegia develops in a con-
siderable number of cases, that bed-sores may be
developed over the sacrum, and that finally a condition
of maniacal excitement with hallucinations, or depres-
sion and coma, may succeed the convulsions.

I have seen cases in which from twenty to fifty
seizures occurred in the course of twenty-four hours.

• The arrest of these convulsions is immediatel}''
attained by the application of pressure to the carotids,
which is best accomplished with an appropriate instru-
ment, f

So-called "■ Jacksoma7i" Epilepsy. — There are cer-
tain forms of local or unilateral spasm, occurring
usually without loss of consciousness, which have been
carefully investigated by Dr. Hughlings Jackson, and

*" Etudes clinique et thermometriques sur les maladies
du systeme nerveux," 1873.

f " Prolonged Instrumental Compression of the Carotids
as a Therapeutic Agent," by J. Leonard Corning, M. D.,
."Medical Record" of February 18, 1882. Also "Philadelphia
Medical News " of June 17, 1883. " Brain Rest," by J. Leon-
ard Corning, M. D., G. P. Putnam's Sons, New York, 1883.
"Carotid Compression," Anson D. F. Randolph & Co., New
York, 1882. "Brain Exhaustion," by J. Leonard Corning.
M. D., D. Appleton & Co., New York, 1884.

— I05 —

which, in accordance with the views entertained by
that observer with respect to their pathology, have
found a place in medical literature under the designa-
tion of "Jacksonian Epilepsy." Since the spasms in
question are almost invariably due to organic intra-
cranial disease, their extended consideration would be
out of place in a work of this character. But, since
most recent systematic writers are in the habit of
devoting some attention to them in connection with
the discussion of the pathology of epilepsy, I have
decided to give a brief sketch of their principal char-
acteristics, reserving their more extended discussion
for a future occasion. While so doing, I can not, how-
ever, refrain from protesting against the inconsistency
of a pathology which would designate phenomena of
this class as epileptic. There is, indeed, no more
pathological similitude between these local spasms and
true idiopathic epilepsy than exists between the latter
and the contractions evoked by the electric current
when applied to the motor centers in the cortex.

It is true that Jackson was anticipated by Bravais*
as far as the description of these unilateral convulsions
is concerned, but it was reserved for the former clini-
cian to thoroughly elucidate the morbid physiology
of the affection. The researches of Dr. Jackson in
this important field are recorded in a series of papers,
which have received a wide and merited attention.

* " Recherches sur les symptomes et le traitement de
I'epilepsis hemiplegique," These, Paris, 1827.

— io6 —

"Jacksonian epilepsy" is characterized by the
occurrence of partial convulsions, which may be limited
to one extremity or to one side of the face, or which,
beginning in one extremity, may extend to the other,
or even involve half of the body. In rare instances
the spasm may extend to the opposite side as well.

As we have already seen, consciousness usually
remains unaffected, or, where unconsciousness takes
place, it is only evident toward the end of the attack,
so that the patient is afterward able to recall what has
taken place before and during the greater portion of
the seizure.

This form of epilepsy owes its origin to coarse
disease situated in or near the cortex. The most fre-
quent cause of the disease is a syphilitic gumma, but
localised cicatrices, wounds, tubercle, meningo-ence-
phalitis, and indeed all forms of circumscribed irrita-
tive lesions of the cortex, may give rise to the spasms.

When we consider the grave nature of such
lesions it is not surprising that the limbs affected by
the convulsions may subsequently become the seat of
temporary or even permanent paralysis. The latter
eventuality is prone to occur where the" lesion, which
at first may have been merely irritative in character,
ultimately destroys that portion of the cortex in which
it is situated, or against which it impinges. This as-
sociation of the unilateral convulsions with secondary
paralysis has given rise to the designation often en-
countered in medical literature of hemiplegic epilepsy

— I07 —

("epilepsia hemipleique "). But why should there be
convulsions associated with these profound cortical
lesions ? Dr. Hughlings Jackson's explanation of this
interesting pathological fact is at once ingenious and
plausible. He believes that the ganglia in the imme-
diate vicinity of the lesion are kept in a state of mor-
bid irritability, and that consequently they are unduly
supplied with blood. As a result of this hyper-irriga-
tion, the ganglion cells absorb an excessive amount of
nutriment, so that their superfluous energy finds a
vent in sudden explosions, the products of which are
the convulsions. These explosions are followed by
exhaustion and inertia of the nerve-centres involved,
and consequent temporary paralysis of the previously
convulsed muscles ensues. As we have already had
occasion to observe, however, irritative lesions of this
character may eventually destroy the motor centres in
the cortex near which they chance to be situated, and
with the result of causing permanent paralysis of the
muscles over which the centres in question preside.

Sensory Epilepsy. — This variety of the affection
has been referred to by Sommers and others, and in a
recent article Dr. Allan McLane Hamilton* has
recorded several cases illustrative of the manifold
phases of this form of epilepsy. In the first case there

*"A Contribution to the Study of Several Unusual
Forms of Sensory Epilepsy which are probably dependent
upon Lesions of the Occipital Cortex," by Allan McLane
Hamilton, M. D., "Medical Record," April 4, 1885.

— io8 —

were sudden hemiopia, supra-orbital neuralgia, unila-
teral anaesthesia of extremities, tongue, and gums,
temporary speech disturbance, and loss of conscious-
ness. In another case there were hemianopsia, frontal
headache, hemianaesthesia, temporary mutism, and
loss of consciousness.

The researches of Krause, D. J. Hamilton, Starr,
Munk, and Wernicke have done much to shed light
upon the morbid physiology of these exceptional
forms of epilepsy; but, as the discussion is still by no
means closed, I shall refrain from entering further into
the consideration of this interesting but obscure mani-
festation.

CHAPTER VL

CAUSATION.

The most potent predisposing cause of epilepsy is
probably found in a hereditary neuropathic tendency
transmitted from the father, mother, or both. Some-
times, however, this hereditary tendency is not readily
discoverable, owing to the fact that one or even
several generations have escaped. This circumstance
accounts, doubtless, in a measure for the conflicting
statistics adduced in favor of or against the theory of
hereditary influence. When carefully collected and
impartially interpreted, there can be little doubt, how-
ever, that statistics go far to prove the great getio-
logical importance of heredity in this as in other
neuroses. It should be borne in mind, in this connec-
tion, that it is not absolutely necessary to trace a series
of epilepsies occurring in successive generations in
order to prove a hereditary influence. On the con-
trary, all that is required is proof of the existence in
the family of a well-marked neuropathic diathesis, ex-
perience having shown that such a morbid tendency
may exhibit itself in almost any form of organic or
functional nervous disease. Regarding the subject
from this standpoint, Herpin* found, out of two

* " Du pronostic et du traitement curatif de I'^pilepsie,"
Paris, 1852.

hundred and forty- three epileptics, well-marked here-
ditary tendencies in forty-three cases.

The cases reported by Petit* of healthy children
occurring in families in which both parents were
epileptic have been cited as testimony calculated to
destroy the integrity of the theory of hereditary influ-
ence. They possess, however, no value whatever so
far as the rebuttal of the evidence upon which that
theory is founded is concerned, since at most such
facts only go to show that one or more generations
may escape from the baneful pre-natal influences — a
fact already sufficiently understood by all medical
statisticians.

Echeverria's opinion that phthisis in the parents
has a tendency to cause epilepsy in the offspring seems
to us well founded, though controverted by Noth-
nagel,f who regards the association of the two diseases
as explained by the great frequency of phthisis. The
fact that a certain condition of instability of the cen-
tral nervous system is engendered by the malnutrition
consequent upon scrofula, anaemia, and chlorosis, and
that such an unstable condition often eventuates in
epilepsy, is indirect evidence of the correctness of
Echeverria's position. Consanguineous marriages
also appear to predispose to the occurrence of the dis-
ease in the offspring.

*Gaz. med. de Paris," i8, i860.
f Op. cit., p. 202.

Alcohol has been considered an important aetio-
logical factor, but evidence on this point is conflicting.
There is no doubt, it is true, that chronic alcohoUsm
and epilepsy are frequently associated; but whether
the former is the outgrowth of the latter, or whether
the epilepsy is to be regarded as the result of the
alcoholic excesses, is difficult of determination.

Age is unquestionably an important predisposing
factor in epilepsy. In one hundred and thirty-eight
cases analyzed by myself, I found that in 25 per cent,
the disease began under eight years, in 5 1 per cent,
between eight and twenty-five, in 13.5 per cent, be-
tween twenty-five and thirty-five, and in 10.5 per cent,
between thirty-five and fifty.

Gower's* statistics differ somewhat from my own;
but since they were derived from the analysis of a
larger number of cases, they are perhaps more exact.
Of 1,450 cases analyzed by this observer, 12.5 per
cent, began during the first three years of life, 29 per
cent, under the tenth year, 46 per cent, between ten
and twenty, and 15.7 per cent, between twenty and
thirty.

Sex has a less obvious influence upon the occur-
rence of the disease than was formerly supposed. The
older writers believed that the disease was more com-
mon among males than females, but their views do

*Vide " British Medical Journal," March 6, 1880, as well
as subsequent communications.

not seem to have been derived from a careful analysis
of statistics, and are apparently nothmg more than
arbitrary assertions. As to recent writers, the opinion
is quite generally expressed that the disease is more
frequent among males than among females, while one
or two observers believe that the proportion between
the two sexes is about equal. For my own part, I
have no hesitancy in expressing the belief that the
disease is at least as common among males as among
females. Of 72 cases of epilepsy which I have re-
cently seen in asylum, dispensary, and infirmary prac-
tice, 41 occurred in men and 31 in women.

It is possible that the relative frequency of the
disease in the sexes may vary somewhat with age; but,
be that as it may, there is no doubt that in ordinary
hospital practice the disease is somewhat more fre-
quent encountered among males than among females.

The factors which may be classed as exciting
causes of the disease are undoubtedly numerous. We
shall, however, discuss only the more frequent and im-
portant of the latter, since to attempt to enumerate
them all would be alike devoid of theoretic or practical
advantage.

In former times much importance was ascribed to
sexual excesses in the production of the disease; but
in more recent times a reversal of this decision is ap-
parent in some quarters, so that at the present day
it is quite in accord with fashion to undervalue, and
even to deny altogether, the setiological importance
of this factor.

— 113 —

From my own observations in connection with
this matter, I can not help believing that modern
writers have been too hasty in their conclusions.

It is an undoubted fact that the great majority of
epileptics are addicted to the practice of masturbation,
and that the habit is quite as prevalent among female
as among male patients. Many recent writers, never-
theless, regard the vice as one of the manifestations
of the disease, and not as one of its causes. The
question is, however, a difficult one to decide, and
arbitrary assertions for or against the proposition are
evidently inadmissible. But, after all, the most im-
portant question to decide is not whether epileptics
masturbate during the disease, on account of the lat-
ter, but whether they were addicted to the vice pre-
vious to the advent of the epileptic symptoms.

Out of seventy-two cases of epilepsy which I in-
vestigated with regard to this point, 84 per cent,
afforded histories of excessive masturbation previous
to the first paroxysm. In one case localized spasms
began in the left hand, after the practice had been
continued for about three years, and in course of time
the convulsions became general. There were no para-
lytic symptoms, and the patient, a young man of
twenty-eight, denied having had syphilis. In the face
of such evidence, I cannot help believing that we are
justified in inferring that a causal connection really
does exist in some cases between persistent masturba-

9 z

— 114 —

tion and the development of that instability of the
central nervous system which is so characteristic of
the epileptic state. Cases in which the first epilep-
tic paroxysm was developed during coitus certainly
lend strength to the argument. The conclusion
is indeed inevitable that sexual excesses constitute a
far more frequent predisposing and exciting cause of
the affection than is admitted by Nothnagel* and
other excellent writers.

' Epilepsy is frequently evoked by such psychical

disturbances as sudden fear, grief, pecuniary and other
forms of anxiety, and indeed by all violent appeals to
the emotional mechanism. Such occurrences un-
questionably constitute some of the prolific exciting
causes of the disease; but it is exremely problematical
whether the epileptic symptoms would have been
evoked were the central nervous system not already
in a state of morbid receptivity.

Epilepsy is also prone to develop in the course of
or subsequent to the occurrence of the febrile disturb-
ances of infancy. It is also frequently developed
after injury to a nerve, or as the result of reflex irrita-
tion induced by teething and other causes.

Sometimes the disease is traceable to some cranial
injury of such apparent insignificance that it has been
speedily forgotten, and only the most careful inquiry
serves to elicit the fact. This applies with particular

* Op. cit., p. 203.

— 115 —

force to young children afflicted with local or general
spasms — cases in which we are compelled to rely upon
the equivocal testimony of nurses and other ignorant
persons. Some of the most severe cases of localized
epilepsy (hemi-epilepsy) which have come under my
observation 'occurred in young children who had been
dropped by nurses, or had met with some other form
of accident at the hands of servants. In all such cases
there is probably always more or less indirect injury
to the brain, with consequent development of grave
organic lesions, though, it is true, there may be no ex-
ternal indication of injury.

Blows upon the cranium are not liable to eventu-
ate in epilepsy, according to some writers, unless they
are of sufficient severity to cause unconsciousness.
This appears to me an altogether too sanguine view of
the matter, since I have seen at least two cases of epi-
lepsy in children which developed soon after blows of
so slight a nature as to be almost forgotten. There is
little doubt in my own mind that the most insignificant
concussion about the head, even when unaccompanied
by evidences of abrasion, may, sooner or later, develop
epileptic symptoms. This observation applies with
particular force to infancy and early childhood,
when the non-resistent character of the cranial bones
facilitates the transmission of sudden shocks to the
brain.

Even where no history of a blow is forthcoming,
there is strong presumptive evidence that there has

— ii6 —

been contusion of some kind. Many cases of epilepsy,
occurring after slight abrasions about the head, have
been ascribed to "reflex" causes; but it is probable
that, in a considerable percentage of such cases, there
is more or less direct disturbance of the cerebral sub-
stance itself, although some time may have elapsed
before the appearance of the first paroxysms. In all
such cases great care should be exercised in forming
an opinion, as to causation, since the prognosis will
manifestly be much less favorable when the paroxysms
are traceable to direct injury than when they are
really of reflex origin.

CHAPTER VII.

EXPERIMENTAL RESEARCHES.

The most important experimental investigations
relative to the pathogeny of epilepsy are those of
Marshall Hall, Sir Astley Cooper, Kussmaul and
Tenner, Landos. Nothnagel, Brown-Sequard, West-
phal, Magnan, Hitzig, and Ferrier.

Before discussing the varfous theories of the dis-
ease, which are directly or indirectly the outgrowth of
these investigations, it will be advisable to review the
experiments themselves, in order the better to appre-
ciate how much objective matter is really embodied in
these hypotheses.

Even among the ancients there is an evident ten-
dency to appropriate the results of the rough experi-
ments at hand to the elucidation of the theory of dis-
ease. Thus, Hippocrates* taught that convulsions
might arise as well from fulness as from want of blood.
He was, doubtless, guided in these statements by ob-
servations made upon animals condemned to die in
the shambles, coupled, perhaps, with considerations
derived from practical experience at the bedside.
Kellie,f who made a series of experiments upon sheep,
and Pioray,J who conducted similar investigations

* "Aphorisms," sec. vi, 48.

fVide "On Bloodletting," by Marshall Hall.

^''Archives generales de medecine," January, 1826.

— ii8 —

upon dogs, found that copious blood-letting was fol-
lowed by convulsions. Marshall Hall* and Travers
were, however, among the first, if not the first, to note
the resemblance between the convulsions produced by
rapid bleeding in man and other warm-blooded ani-
mals and the spasms of epilepsy.

Although, as already noted, the ancients and
older medical writers had formed opinions relative to
the role played by the intra-cranial blood-stream —
theories which, even at the present day, bear evidence
of a high degree of perspicuity — it is commonly con-
ceded that the fundamental experiments undertaken
by Sir Astley Cooperf in 1831 really paved the way
for the scientific study of epilepsy. These experi-
ments consisted in ligation of the vertebral and carotid
arteries; of both carotid arteries; of both vertebral
arteries. Then, ligation of the carotids first and of
the vertebrals nine days afterward; of the carotids and
subsequent compression of the vertebrals; and, finally,
ligation of the vertebrals and subsequent compression
of the carotids.

Of these experiments, that in which the carotids
were first ligated, and the vertebral arteries immedi-
ately afterward compressed, is perhaps the most im-

* Op. cit.

f " Some Experiments and Observations on tying the
Carotid and Verteoral Arteries," by Sir Astley Cooper.
"Guy's Hospital Reports," 1836, vol. i, p. 458 et seq. The ex-
periment, cited at length, is continued on pages 465, 466.

— 119 —

portant; and I cannot therefore do better than quote
the same, in the words of Sir Astley Cooper himself:

" As tying the vertebral arteries is a difficult ex-
periment, it occurred to me that I might compress
them with my fingers, after tying the carotids, and
produce the same effects.

"I tied the carotid arteries; respiration was some-
what quickened, and the heart's action increased, but
no other effect was produced. In five minutes the
vertebral arteries were compressed by the thumbs, the
trachea being completely excluded. Respiration al-
most directly stopped, convulsive struggles 'succeeded,
the animal lost consciousness, and appeared dead. The
pressure was removed, and it recovered with a con-
vulsive inspiration. It lay upon its side, making vio-
lent convulsive efforts, breathing laboriously, and its
heart beat rapidly.

" In two hours it had recovered, but its respira-
tion was laborious.

" The vertebrals were compressed a second time.
Respiration stopped; then succeeded convulsive
struggles, loss of motion and apparent death.

" When let loose, its natural functions returned
with a loud inspiration, and with breathing excessively
labored.

" In four hours it was moving about and ate some
greens.

In five hours the vetebral arteries were com-
pressed a third time, and with the same effect.

" In seven hours it was cleaning its face with its
paws.

" In nine hours the vertebral arteries were com-
pressed for the fourth time, and with the same effect
upon its respiration.

" After thirteen hours it was lively.

" In twenty-four hours the vertebral arteries were
compressed for a fifth time, and the result was the
same — namely, suspended respiration, convulsions,
loss of motion and consciousness. On the removal of
pressure, violent and laborious respiration ensued, and
afterward the breathing became very quick.

" After forty-eight hours, for the sixth time, the
compression was applied, with the same effect."

These experiments of Sir Astley Cooper have
shown, then, that ligature of both carotids and simul-
taneous compression of the vertebrals give rise to uncoti-
sciousness, suspension of respiration, and convulsions.

Subsequently Kussmaul and Tenner * repeated
these experiments in a much more perfect manner up-
on dogs, cats, and rabbits, and succeeded in conclu-
sively demonstrating that rapid and profuse haemor-
rhage is followed by violent and general convulsions.
" If," however, " haemorrhage takes place slowly, and
the vital powers are gradually consumed, death ap-

*Moleschott's " Untersuchungen," Band ii, p. 248, 1857.
Also "Epileptiform Convulsions caused by Profuse Bleeding,"
etc.. by Adolf Kussmaul and Adolf Tenner. The New Syden-
ham Society, London, 1859.

pears then to ensue with swooning, drowsiness, de-
lirium, and vascular irritation without convulsions."

" More than twenty rabbits, which we either
killed intentionally by rapid bleeding, or which ex-
pired while being experimented upon, died under
general convulsions like those observed in epilepsy,
and which we shall afterward more fully describe.
Not one of those which we saw die bleeding was ex-
empt from convulsions. These convulsions did not
differ in any respect from those we observed in several
dogs and cats that died from bleeding, or from those
described as occurring in men dying from haemor-
rhage."*

Kussmaul and Tenner have also shown that an
interruption in the conveyance of arterial blood to the
brain of a rabbit produces epileptic fits with as much
certainty as general haemorrhage. Referring to the
point, they state that " no difference, moreover, could
be discerned between the fits observed in death from
bleeding and those which occurred in about one hun-
dred rabbits whose carotid and subclavian arteries
were tied or compressed below the origin of the
vertebral arteries."

And again: "Lastly, we become convinced, by
observation of more than a dozen rabbits, that the fits
produced by compression of the above-mentioned
arteries resemble in every way those brought on acci-

* Op. cit., p, 2, foot-note.

dentally or intentionally in the identical * animals by
profuse haemorrhage after circulation has been re-
stored to the head."

* The Italics are ours.

CHAPTER VIII.

EXPERIMENTAL RESEARCHES CONTINUED.

I can not refrain from giving a description of the
convulsive paroxysms induced in rabbits after ligature
of the great arteries of the neck, in the eloquent
language of Kussmaul and Tenner. The quotation is
made from the paper already referred to:

" General convulsions usually followed in from eight to
eighteen seconds after complete withdrawal of arterial blood.
We killed six rabbits solely for the purpose of determining in
what space of time convulsions would come on. After the
arteries had been laid bare, and the ligatures had been passed
lound, we allowed the animals to rest undisturbed in an erect
position for a quarter of an hour, without making any experi-
ments by compression. One of us then as quickly as possible,
tied the left subclavian and innominate arteries, while another,
watch in hand, observed the time when the symptoms first
manifested themselves.

" In a very strong male rabbit, two years old, general con-
vulsions came on three seconds after the innominate had been
tied : and this is the shortest period that we have noticed in
any. In two female white rabbits, four weeks old, the convul-
sions appeared after an interval of twelve seconds; in a female
gray rabbit, two or three years old, in ten seconds; in a male
of the same age, in sixteen seconds; and in an old strong fe-
male, from four to five years old, in forty-five seconds. None
of these animals lost during the operations any considerable
quantity of blood.

" Out of a hundred strong rabbits, we met with four only

124 —

in which, after perfect closure of the above-named vessels, con-
vulsions did not appear till after four to six minutes, and one
only, as already mentioned, in which they did not appear at all
after the lapse of ten minutes, and until the aorta had been
opened."

The occurrence of convulsions is always preceded
by various motor phenomena, which have been ex-
haustively described by KussmauL* The most im-
portant of these are as follows:

1. " Immediately after stoppage of the blood the
various sphincter muscles of the face contract, especi-
ally, and in a very striking manner, those of the iris
and eyelids; then, in the order of their distinctness,
the conchse of the ears, the nostrils, and the mouth.
The jaws, which are generally already closed, become
spasmodically locked. Then, usually a little before,
but sometimes simultaneously upon the occurrence of
general convulsions, the pupils and the fissures of the
eyelids, ears, and nostrils are widened, sometimes the
mouth also, very distinctly. The adductors of the
lower jaw seem also for a few moments to become
paralyzed; but during the attack the jaw becomes
locked, either uninterruptedly or in broken succession,
by the alternate occurrence of spasmodic and more
feeble abductions and stronger adductiofis ."

2. '' Convulsive efforts are almost invariably
made to turn the pupils toward the internal angles

* Vide article by Adolf Kussmaul in " Zeitschrift des
Wurtzburg. phys. med. Vereins."

— 125 —

of the eyes, after which the eyeballs generally roll
about, first inward, forward, and downward, then out-
ward, backward, and upward, until at length the
pupils are turned toward the external angles of the
eyes, and are wholly or partially concealed by the
upper eyelids."

3. " The eyeballs are first drawn back into the
sockets, and again become prominent as the pupils di-
late."

4. " Respiration is at first accelerated, but short-
ly afterward, a little while before the approach of
the general convulsions, it becomes prolonged and
deep."

5. " The muscles of the neck generally become
paralyzed and unable to bear the weight of the head,
which sinks down upon the breast or side, the ani-
mals afterward falling down in a swoon on their fore
feet, occasionally on their hind ones. The symptoms
of paralysis are the more distinct and constant the
greater the time that elapses before general convul-
sions come on."

" The signal for general convulsions is given by a
tonic contraction of the muscles of the neck. Then
commences a terrible scene, the more surprising by
contrast if preceded by swooning. The head is drawn
violently backward, the pupil becomes uncommonly
enlarged, violent lock-jaw ensues, and the animal, if
strong, is generally flung forward with great force to
a distance even of from one to two feet, and some-

126

times over the shoulders of the observer seated before
it. The legs are alternately contracted and extended
by clonic convulsions in the most violent way; the en-
larged pupil appears again fixed in the centre of the
palpebral fissure, as the eyeball is again rolled some-
what inward; respiration is scarcely to be perceived,
while the heart continues throbbing very vigorously.
The clonic convulsions gradually subside, assuming
more the appearance of tetanus, and eventually disap-
pear altogether, passing away as they do so from the
front to the back. First, the muscles of the neck and
fore legs become paralyzed, while the back part of the
body is bent forward and the hind legs are tetanically
extended until these movements also cease. The
duration of these attacks was, according to several ob-
servations, from eighteen seconds to two minutes.

" Very frequently, after a pause of from fifteen to
seventy-five seconds, a second attack comes on, always
weaker and shorter than the first, and often limited to
the hinder part of the body, in the form of tetanic
convulsions; sometimes, however, affecting, the whole
body, under the form of clonic convulsions. We once
observed such a second attack to last, in an exception-
al case, two minutes. Sometimes, indeed, convulsions,
in which the hind legs become tetanically stretched,
recur even for a third and fourth time, at intervals of
from fifteen to thirty seconds. They returned in
the strongest and most regular manner in those
animals whose arteries were tied forthwith, and whose

127 —

strength had not been previously exhausted by experi-
ments of compression. Toward the end of the attacks,
urine and faeces were sometimes voided; at other
times no such voiding took place, even when the
bladder was full.

" In rabbits, cats, and dogs, dying from haemor-
rhage, the convulsions are of exactly the same char-
acter.

"These convulsions present precisely similar
features to those of epilepsy in their complete form, as
the following enumeration of the most important
symptoms will show:

1. " The animals fall down before general con-
vulsions come on, and completely lose the spontaneous
use of their muscles."

2. " They give the observer the impression of
their being perfectly unconscious."

3. " Not one of the many animals operated upon
cried out, so long as the circulation was interrupted,
either before or during the spasmodic attack, and two
only while the latter was abating. Subsequently,
however, they began to cry piteously directly arterial
blood began to flow again, or, at all events, soon after-
ward. From the want of power to cry, and from the
gradual swelling of the veins of the brain during the
attack, to which we shall direct attention further on,
we infer that spasm of the glottis (laryngismus) took
place."

4. " The pupils are dilated during the attacks,

— 128 —

and, to judge from several experiments, appear rigid,
the eyeballs bemg motionless. Before and subsequent
to the attacks, however, and when • at the very last
gasp, the pupils being at the same time very much en-
larged, the eyes of some animals that were accurately
examined appeared sensible to the influence of light."

5. " The attacks commence with a toxic spasm
of the neck (trachelismus.)"

6. " Respiration ceases, while the heart con-
tinues beating."

7. " The limbs are seized with strong clonic con-
vulsions, and become at last spasmodically stretched."

Besides the experiments above referred to, Kuss-
maul and Tenner inaugurated a series of researches
which had for their object the more precise localiza-
tion of the cerebral regions from whence general con-
vulsions arise.*

The modus operandi in these researches was as fol-
lows: Various districts of the brain were cut out, and
a comparison of the effects produced by compressing
the great arteries of the head before and after the
operation was instituted. In this manner the follow-
ing conclusions were arrived at: That anaemia of
those parts of the brain situated in front of the crura

*On the Mode of Procedure for Determining the Cerebral
Region from whence General Convulsions after Profuse
Haemorrhage Arise," by Adolf KussmuU and Adolf Tenner.
"The New Sydenham Soc," 1859, vol. v, p. to et seq.

129 —

cerebri produces unconscioueness, insensibility, and
paralysis, if spasms occur with these symptoms, some
excitable parts behind the thalami optici must have
likewise undergone some change.*

This portion of their experiments is, however,
open to criticism, since the sources of error are numer-
ous. Among the latter, I will only mention the com-
plications liable to arise from opening the skull — a
procedure inevitably accompanied by changes in pres-
sure, and, in this case, by escape of the cerebro-spinal
fluid, and no little hsemorrhage.

I shall take occasion to refer at length to the
further conclusions arrived at by Kussmaul and
Tenner relative to the pathology of epilepsy in the
subsequent paragraph on the mechanism of the
epileptic seizure.

Landois has conducted some interesting experi-
ments, which show the relation of venous hyperemia
of the brain and superior portion of the spinal cord to
epileptoid convulsions, f

The mode of procedure in these researches was
as follows: The right thoracic cavity was opened and
the superior vena cava exposed in such wise that it

* Vide under head of General Summary, op. cit., p. 105.

f " Ueber den Einfluss der venosen Hyperamie des
Gehirns und des verlangerten Markes auf die Herzbewegung,
nebst Bemerkungen liber die fallsuchtartigen Anfalle,"von Dr.
Leonard Landois. " Centralblatt fur die medicinischen Wis-
senschaften," p. 146, 1867.

was possible to close the lumen of the same by means
of an ordinary artery forceps. Artificial respiration
was instituted, in order to neutralize as far as possible
the respiratory derangements unavoidably arising from
opening one side or the thorax.

Among other phenomena, Landois observed, after
closure of the superior vena cava (in the rabbit): i.
Retardation of the heart's action; and, 2, "Complete
epileptoid seizures."

The latter observation is one of great importance
from a pathogenic point of view, since we are thus
made aware not only that cerebral anaemia is capable
of producing epileptoid convulsions (as shown by
Kussmaul and Tenner), but that profound venous
hypersemia of the central nervous system is equally
provocative of the same phenomena.* We can readily
understand, moreover, why the convulsions are per-
petuated during the second stage of the epileptic
attack — that period of the seizure when the brain is
evidently in a state of profound venous engorgement.

In 1868, Dr. H. Nothnagelf drew attention . to
the fact that, although it had long been known that
irritation of the floor of the fourth ventricle gave rise to
irregular general convulsions, no attempt had been

* " Die Entstehung allgemeiner Convulsionen von Pons
und von der Medulla oblongata aus," von Dr. D. Nothnagel.
"Archiv. fiir pathologische Anatomie und Physiologie und fUr
klinische Medicin," Bd. xliv, p. i, 1868.

f Op. cic, pp. 146 and 147.

— 131 —
made to locate the district in question with greater pre-
cision. That more exact researches in this regard
were really necessary was proved by the fact that ex-
periments, undertaken in the light of the popular con-
ception with regard to the '•convulsive" functions of
the floor of the fourth verticle, frequently failed to
produce any spasmodic phenomena whatsoever.

Accordingly, Nothnagel instituted a series of ex-
periments with a view to determining with greater
precision the locality in the medulla whose irritation is
followed by general convulsions.

The technique of these experiments was extremely
simple. The animal was placed upon the abdomen
and secured with appropriate appliances. The soft
parts were then divided so as to expose the occipital
portion of the head between the crista and protuber-
antia occipitalis. Then the skull was pierced by
means of a strong needle (care being taked to avoid
the openings for the vasa emissaria Santorini). Finally,
penetration of the organs within was effected by means
of a fine needle. This procedure was followed by
compulsory movements, general epileptoid convulsions,
or the animal remained perfectly quiet, according to
the part penetrated. Confirmatory evidence was sub-
sequently afforded by post-mortem examination.

In this simple manner Nothnagel was able to de-
termine with great exactness the boundaries of what
he has expressively termed the "convulsion center"
{Krampfbezirk). The lower limit of this district is

— 132 —

situated at the upper portion of the alcz cineretz; the
upper limit lies somewhat above the locus cceruleus;
the inner limit is constituted by the outer lateral border
of the eminenticz teretesj the outer limit is more difficult
to locate, but the upper boundary line appears to be
formed by the locus cceruleus, whereas, below it corre-
sponds to the inner border of the tuberculum acusti-
cum.^

The depth of the district is very difficult to deter-
mine, as the slightest movement on the part of the
hand of the operator causes the needle to penetrate
unduly the yielding nervous tissue. When the needle
penetrates the above mentioned district (the "convul-
sion center"), the following phenomena are observed:

"At the moment of penetration severe opisthot-
onus and tetanic extension of the spinal column take
place. Although firmly secured, the animal makes
spasmodic movements with the extremities. When
released it presents the spectacle of the most pro-
nounced epileptoid convulsions. The extremities are
the seat of violent irregular contractions, the posterior
being sometimes more affected than the anterior limbs.
At the same time the entire animal is thrown from
side to side. ... In from one-half to three minutes
the violence of the paroxysms subsides, and the ani-
mal remains quiet, but the extremities still continue
extended and the spinal column is perfectly rigid." A

* Op. cit., p. 5.

— ^33 —

blow upon the table is sufficient to again evoke the
convulsions, but the latter sometimes break forth anew
spontaneously.

From these experiments, Nothnagel concludes
that the central point of departure of general convul-
sions is to be sought for in the pons. The lower limit
of that portion of the central nervous system which is
the point of departure of general epileptiform convul-
sions is represented by a transverse section situated at
the lower boundary of the pons.*

These, then, are the experiments upon which
Nothnagel has founded his theory of epilepsy. I shall
take occasion to again refer to the latter in the subse-
quent paragraph on the nature of the paroxysm.

In 1850 Dr. JBrown-Sequard f succeeded in de-
monstrating that certain lesions of the spinal cord in
mammals are followed in a few weeks by convulsions
bearing a strong resemblance to those of epilepsy.
After a long series of experiments on guinea-pigs, he
found, moreover, that all the lesions of the cord
enumerated below are capable of evoking these con-
vulsive phenomena:

I. Complete or almost complete transverse sec-
tion of one lateral half of the cord

* Op. cit., p. 9.

f Vide "Comptes rendus de la Societe de biologic," 1850,
vol. ii; "Archives generales de medecine," 1856, vol. i (v. serie,
tome 7), p. 143; "Lancet," 1861; "Bull, de 1' Academic de
med. de Paris," Jan., mals," etc., 1857.

— 134 —

2. Simultaneous transverse section of the poste-
rior columnSjOf the posterior horns of gray matter, and
of a portion of the lateral columns.

3. Transverse section of the posterior columns,
or of the lateral columns, or of the anterior columns
alone.

4. Complete transverse section of the cord.

5. Simple puncture of the cord.

Of these lesions, the first two are apparently those
which are most liable to develop the convulsive condi-
tion.

That portion of the cord situated between the
seventh or eighth dorsal and the third lumbar verte-
brae is most susceptible to wounds. Lesions of this
region are particularly prone to develope the convul-
sive condition.

In the majority of cases, the convulsive symptoms
appear during the third week subsequeut to the lesion.

Sometimes the convulsions appear without the
aid of extraneous excitation. As a rule, however,
they are readily evoked by irritation of certain circum-
scribed portions of the integument. That portion of
the body the irritation of which causes convulsions
has been termed by Brown-Sequard the ^'' epileptogenous
zone''

This author has also shown that section of the
more important nerve-trunks, such as the internal
popliteal and sciatic, and also lesions of the crura cere-

— '35 —
bri or corpora quadrigemina, are particularly prone to
develop the epileptic condition.*

The offspring of animals affected by epilepsy
caused by lesions of the nervous system may develop
the epileptic condition, as Dr. Brown-Sequard has
conclusively demonstrated.

A suggestive circumstance in connection with the
epileptogenous zone is the fact that the latter is always
situated on the same side as the lesion of the spinal
cord or nerve; but, when the crus cerebri is injured,
it is found on the opposite side of the lesion.

Westphal,f while endeavoring to determine
whether the epileptoid convulsions previously de-
scribed by Brown-Sequard might be determined by
certain injuries to the skin, discovered the interesting
fact that, when a guinea-pig receives a blow, or a
series of blows upon the head, the animal is at once
seized with a violent convulsive attack. The convul-
sions thus induced resemble in every respect those
produced by Brown-Sequard in the same animal by
injuries to the nerves or spinal cord. The seizure
takes place immediately after the blow, or after the
lapse of a few minutes. When the convulsions have
subsided, the animal appears to recover its normal
condition; and attempts to cause a renewal of the

* " Researches on Epilepsy," etc., by Brown-Sequard,
1857. Also articles in journals already referred to.

f " Ueber kiinstliche Erzeugung von Epilepsie bie Meer-
schweinchen," Berliner klinische Wochenschrift, No. 38, 1871.

— 136 —

seizure by irritating that portion of the skin which
Brown-Sequard has called the " epileptogenous zone "
are without avail. A different state of things is, how-
ever, observed to exist after the lapse of a few weeks;
for, if now the animal is irritated by pinching, par-
ticularly in the neighborhood of the lower jaw, an at-
tack of convulsions is immediately produced.

The susceptibility to a convulsive condition
evoked by blows is hereditary, like the corresponding
state which Brown-Sequard succeeded in establishing
by means of injuries to the spinal cord and nerve-
trunks. f

Dr. V. Magnan J and M. Challand § have shown
in animals that absinthe, when introduced into the
system, produces convulsions of an epileptoid char-
acter. The following experiment, performed by Dr.
Magnan on a dog, is most interesting, as showing the
possibility of producing hallucinations as well as
epileptic attacks by the administration of absinthe:
" In a dog weighing thirty-one pounds, into whose
stomach we injected five grammes (about seventy-five
minims) of essence of absinthe at 9:15 a. m., we ob-

t Op. dtp. 45 r.

I "On Alcoholism, the Various Forms of Alcoholic
Delirium and their Treatment," by Dr. V. Magnan, London,
1876, p. 26.

§ Challand. "' Experiments made at the Hotel Dieu at
Professor Behier's Clinique," cited by Dr. Magnan in his
monograph on " Alcoholism," p. 26 et seq.

— 137 —

served a first attack of epilepsy at 9:45 a. m.; ten
minutes later a second attack occurs, followed by a
slight degree of stupor; quickly becoming himself
again, the animal continues playful, answers a call,
walks and runs easily. Quite suddenly, and without
any provocation, he raises himself on his feet, with
hair bristling, angry look, eyes injected and brilliant;
he fixes his gaze on a wall which is completely bare,
and on which there is nothing to draw his attention;
bending down with the paws forward and the neck
stretched ready to spring, he advances and recoils
alternately, barks furiously, and gives himself up to a
furious battle; clashing his jaws, and making sudden
movements as if to seize an enemy, he shakes his head
from side to side, clinching his teeth as if to tear his
prey. By degrees he becomes calm, but still looks
several times in the same direction, growling, and then
regains confidence completely."

Finally, it is worthy of note that both Ferrier and
Bartholow have succeeded in evoking epileptoid
convulsions by the direct application of the faradaic
current to the brain. Convulsions have also been
caused by injury to the cortical motor areas. f In all
experiments of this nature, in which electricity is em-
ployed for the purpose of exciting the nervous sub-

* Op. et loc. cit.

f " Untersuchungen tiber das Gehirn," 1864, and other
writings of Hitzig.

- 138 -

stance, it should be borne in mind that the localiza-
tion of the current is a matter of so much difficulty
that great caution should be exercised in drawing con-
clusions as to the relative functional importance of
neighboring districts.

Having thus reviewed in succession those experi-
mental researches which are best calculated to shed
light upon the intricate questions of pathology in-
volved, it now remains to discuss the mechanism of
the attack itself — a task which will be greatly facili-
tated by the preliminary knowledge at our disposal

CHAPTER IX.

PATHO-ANATOMICAL FINDINGS.

So various have been the changes recorded by
pathologists in epilepsy that, if an attempt were made
to construct an explanation of the seizure upon such a
basis, it would be found to resemble in intricacy a
veritable Gordian knot. There is, in truth, hardly an
organ in the entire body which has not been found
diseased in this affection. Ignoring the morbid
changes in the viscera, which are evidently of colla-
teral importance, it will be well for the completeness
of the argument to bestow a glance upon the more
striking appearances found in the brain, medulla, and
the remaining portions of the cord, and their appen-
dices.

First of all, then, it has been affirmed that the
weight of the brain is increased in epilepsy;* but, on
the other hand, equally positive statements are at hand
which go to show that, in some cases at least, the
weight of the organ is decreased. f

Unequal proportions of the two hemispheres has
also been alleged, but is certainly by no hieans so fre-
quently met with as was formerly supposed.

Meynert and others have found sclerosis of the

* Echeverria, "On Epilepsy," New York, 1870.

f Meynert, " Vierteljahrasschrift fiir Psychiatric," 1867.

— 140 —

cornu Ammonis, but I believe he rightly considers this
change of secondary origin only. But I would go a
step further and maintain that the lesion in question
can not possess the slightest importance whatever, so
far as the development of the paroxysm is concerned,
since, when this portion of the brain is removed, con-
vulsive phenomena are neither evoked nor increased
when they already exist.

Without entering upon a recapitulation of the
various tumors which have been found associated
with epileptic phenomena, I will content myself with
enumerating some of the further and more obvious
changes about the cord and brain which have been
noted within the last few years: (i) atheroma and
aneurism of blood-vessels; (2) dilatation of the vessels
of the superior portion of the cord; (3) temporary or
permanent anaemia of the brain, resulting from general
causes or from local vaso-motor insufficiency; (4) in-
crease in quantity of the cerebro-spinal fluid; (5) thick-
ening of the meninges of the brain.

Of these changes, the latter must be regarded as
of most importance, since it is found in a considerable
number of cases. But, though cortical function is in-
terfered with in all true cases of epilepsy, it would be
a decided mistake to ascribe such alterations to men-
ingeal changes, since in a by no means insignificant
number of cases neither they nor indeed any other
morbid appearances are discernible, even upon the
closest and most improved methods of scrutiny.

— 141 —

There is consequently no question in my own mind
that, where these evidences of meningitis do occur,
they are, like most of the other changes recorded, to
be regarded as of purely secondary origin — to be ac-
counted for, perhaps, by the violent circulator}" fluctua-
tions which are so characteristic of the disease.

Still, when once established, these thickened
membranes have an undoubted influence upon the
prognosis. Thus, in three cases of severe epilepsy,
with psychical complications, in which I have made
post-mortem examinations, these thickened and ad-
herent members were a prominent feature. In such
cases there is, I believe, little or no chance of either
recovery or benefit, since the derangements in cortical
nutrition caused by such lesions must of necessity be
profound in character, and practically irremediable.

CHAPTER X.

THE MECHANISM OF THE EPILEPTIC SEIZURE.

Enough has already been said concerning the
various morbid anatomical findings in epilepsy to
prove conclusively that there is absolutely nothing
either characteristic or constant in their occurrence.
Consequently, if epilepsy is to be regarded as a
malady /(?r se, and not as a mere symptom of multi-
tudinous forms of central nervous disease, we must
look elsewhere for an adequate explanation of the
true nature of the affection. Undoubtedly the most
consistent theory of the disease is based upon con-
siderations derived from experimental physiology and
pathology.

Without anticipating further, however, it will be
well to review briefly the more prominent hypotheses
relative to the nature of the disease which have been
advanced by various writers on the subject from time
to time.

According to Marshall Hall,* the mechanism of

* The following are the principal writings in which Mar-
shall Hall has embodied his views relative to the pathology of
epilepsy: " Essays on the Theory of Convulsive Diseases and
Derangements of the Nervous System;" "Synopsis of Cerebral
and Spinal Seizures of Inorganic Origin and of Paroxysmal
Form;" " Synopsis of Apoplexy arid Epilepsy, with Observa-
tions on Trachelismus, Laryngismus, and, Tracheotomy," 1852;
" On the Neck as a Medical Region," " Lancet," 1849; "Me-
moirs on the Nervous System," London, 1837.

— 143 —
the seizure may be formulated somewhat as follows:
(i) excitation of a sensory nerve or direct central ex-
citation, which gives rise in the first place to reflex
spasm of the muscles of the neck, causing compression
of the cervical veins with consequent comatose symp-
toms; and, secondly, to a reflex tonic spasm of the
muscles of the larynx, closing of the rima glottidis
(laryngismus), causing asphyxia with consequent con-
vulsions In other words, the condition of uncon-
sciousness is ascribed to venous engorgement, and the
convulsions to general asphyxia.

Plausibility was lent to that portion of the theory
which assumes contraction of the muscles of the neck
as the cause of the venous stasis by the experiments
of Reynolds This observer found that contraction
of the cervical muscles actually did produce stasis of
the veins of the neck, with concomitant cerebral dis-
turbances. But, on the other hand, Kussmaul and
Tenner* have shown, by conclusive experiments, that
occlusion of the larynx is capable of producing both
coma and convulsions. As a consequence, they refuse
to accept the first portion of Hall's theory. It may be
well to add in this connection that both of these ob-
servers guided by clinical and experimental data, ar-
rived at the conclusion that the phenomena of the
affection, and particularly the unconsciousness, could

^^^^"^the Nature and Origin of Epileptiform Convulsions
caused by Profuse Bleeding." by A. Kussmaul and A. Tenner.
"New Sydenham Society," 1859.

— 144 —

not be accounted for by any merely local anatomical
lesion, since the concomitant participation of the cere-
brum was evidently a sine qua no7i. Moreover, they
conclude that it is not necessary to assume a constant
or gross change appreciable by the pathological ana-
tomist, but that a pervasive functional change of tran-
sient duration is sufficient to account for the pheno-
mena of the ordinary epileptic seizure. Such a per-
vasive, transitory change they perceive in cerebral
anaemia — a condition which, as is well known, consti-
tutes a prominent feature of the first portion of the
epileptic attack. Besides this clinical fact, they ad-
duce the evidence afforded by their own experimental
researches, to which extended reference has already
been made, by which it was conclusively shown that,
when the brain of an animal is suddenly deprived of
arterial blood, either by ligation or compression of the
four great arteries which supply the brain, or by bleed-
ing, epileptic convulsions and coma are invariably pro-
duced."^ These observers also endeavored to cause

* These researches, as we have already seen, were, to a
certain extent, anticipated by Sir Astley Cooper (vide " Guy's
Hospital Reports," vol. i, 1836), who succeeded in demonstra-
ting upon rabbits that ligation of both carotids and compres-
sion of the vertebrals gave rise to convulsions, suspension of
respiration, and unconsciousness. The experiments of Kuss-
maul and Tenner were, however, more thorough, and were
conducted upon cats and dogs as well as rabbits (vide Moles-
choot's " UnterVsuchungen," 1857, Bd. ii. pp. 247, 248 et seq. ;
also, " Epileptiform Convulsions caused by Profuse Bleeding,"
by Adolf Kussmaul and Adolf Tenner, " The New Sydenham
Society," London, 1859).

— 145 —
convulsions by faradization of the sympathetic nerves.
Only in one case, however, were their efforts success-
ful; but, had the interrupted galvanic current been
employed, it is possible that more uniform results
might have been obtained. These failures are, how-
ever, not to be accepted as absolutely negative, or as
fatally damaging to the general argument advanced
by these gentlemen, since their experiments with
arterial compression and ligation served to show that
the profound cerebral anaemia resulting therefrom
invariably evoked general convulsions and uncon-
sciousness.

But, while recognizing the important part played
by cerebral anaemia in the i7nmediate production of the
epileptic attack, Kussmaul and Tenner do not fail to
note that behind all this there must be an ultimate
morbid state — an epileptic " condition " or an epileptic
" affection " which is responsible for the occurrence
of all the phenomena concerned in the produc-
tion of the seizure. In speaking of this " proximate "
or ultimate cause of the attack they proceed to state
"that the proximate cause of the attacks can not be
one of long duration, but an alteration merely of a
temporary kind. ... It must be quickly de-
veloped to its full fextent, and pass during the attack
through its different phases, and, when the latter are
over, cease completely or nearly so. How otherwise
is it reconcilable that, after an attack, the patient so
frequently, and often for so long a time, recovers the

— 146 —

full use of the action of the brain ?" And again: "It
can be no visible alteration of the brain, anatomically
demonstrable, that can act as the proximate cause of
an epileptic attack. . . . Every physician of the
present day, who is at all judicious, will relinquish the
hope, cherished with childish confidence by certain
schools and times, that pathological anatomy is destined
to give an explanation of the nature and seat of epi-
lepsy, and he will only expect that result from the
progress of the experimental physiology of the nerves.
Material alterations in the brain and its membranous
and osseous coverings are, it is true, most frequently
found in those who have died from epilepsy and
eclampsia, and are often enough recognized as the
cause during life. Often, however, in spite of most
careful examinations, no anatomically demonstrable
alterations are found in the structure of the brain, and
those which do exist must be generally regarded, es-
pecially in epilepsy, as produced by interruptions to
the circulation and nutrition during the attacks, par-
ticularly if the latter have frequently been repeated
and for a long time. Most of the patients suffering
from this disease for years afford the usual appear-
ances found in chronic diseases of the brain. . . ."
But " not one of all the anatomical alterations in whose
train epilepsy frequently appears — such as cicatrices,
tubercles, and atrophy of the brain, or premature
coalescence of the sutures of the skull, with lessening
of its cavity — leads invariably to this disease."

— 147 —

The " disposition," then, " is nothing else but
that state of the brain which forms the basis from
which the attacks arise, and can scarcely be conceived
of otherwise than as a very slight alteration of the
whole brain, or of a narrowly circumscribed district,
while the alteration which is the cause of the attacks
must always affect the whole substance of the brain,
or at all events the greatest part of it, and that, more-
over, in an energetic manner."

The following is a general summary of the more
important conclusions which Kussmaul and Tenner
derived from their long series of experiments:

1. " The convulsions appearing in profuse hem-
orrhage of warm-blooded animals (including man) re-
semble those observed in epilepsy."

2. "When the brain is suddenly deprived of its
red blood, convulsions ensue of the same description
as those occurring subsequent to ligature of the great
arteries of the neck."

3. '' Epileptic convulsions are likewise brought
on when the arterial blood rapidly assumes a venous
character, as, for example, when a ligature is applied
to the trachea."

4. " It is highly probable that in these cases the
attack of spasms depends upon the suddenly inter-
rupted nutrition of the brain. It is not caused by the
altered pressure which the brain undergoes."

5. "Epileptic convulsions in haemorrhage do not
proceed from the spinal cord."

5- "Neither do they proceed from the cere-
brum."

7. "Their central seat is to be sought for in the
excitable districts of the brain lying behind the thalami
optici."

8. "Anaemia of those parts of the brain situated
in front of the crura cerebri produces unconsciousness,
insensibility, and paralysis in human beings; if spasms
occur with these symptoms, some excitable parts be-
hind the thalami optici must have likewise undergone
some change."

9. " Anaemia of the spinal cord produces paraly-
sis of the limbs, of the muscles of the trunk, and of
respiration. When the anaemia suddenly attains its
greatest intensity, then only, and even then but rarely,
do slight trembling of the limbs precede paralysis.
The sphincter ani acts analogously to the constrictor
muscle of the face in anaemia of the brain^that is, it
contracts spasmodically before it relaxes."

A more explicit account of the experiments from
which Kussmaul and Tenner derived these conclusions
has already been given in the paragraphs on "Experi-
mental Researches." These experiments constitute,
without doubt, one of the most brilliant chapters in the
whole range of experimental pathology, and it is diffi-
cult to conceive how a theory of epilepsy possessing
the slightest title to consistency could have been for-
mulated had they never been undertaken.

While it is doubtful whether some of the opinions

— 149 —

expressed by these gifted authors can at present re-
ceive unqualified indorsement, there is no denying
the great perspicuity displayed throughout the entire
argument. When interpreted, moreover, from the
broad standpoint of more recent scientific acquisitions,
their importance to scientific medicine can hardly be
overestimated.

Finally, I will add that I have been able to con-
firm many of the statements and conclusions of Kuss-
maul and Tenner by researches conducted on human
beings. As I shall have occasion to refer at some
length to these researches in other portions of this
article, I will content myself with merely indicating
the titles of the more important papers and mono-
graphs in which they are embodied.*

* Vide "Medical Record, ' February 18,1882. Article
on "Sleep," "Medical Record " July, 1872. Monograph on
"Carotid Compression," Anson D. F. Randolph & Co., New
York. 1882. Paper read before the New York Neurological
Society, June 6, 1882, and subsequently published in the " Phil-
adelphia News" of June 17, 1S82, and also in the "Ameri-
can Journal of Neurology and Psychiatry," 1882. A paper on
" Electrization of the Sympathetic and Pneumogastric Nerves,
with Simultaneous Bilateral Compression of the Carotids,"
" New York Medical Journal," February 23, 1884. Monograph
on "Brain Rest," G. P. Putnam's Sons, New York, 1883. A
treatise on " Brain Exhaustion," with some preliminary con-
siderations on cerebral dynamics, by J. Leonard Corning,
M. D., D. Appleton & Co., 1884. "The Electro-mechanical
Tonus of the Cortical Blood-vessels," a paper read before the
New York Neurological Society, and subsequently published
in the " Medical Record," February, 1885.

— 15° —

Nothnagel,* as we have already seen, has formu-
lated a theory of the paroxysm, which is the outgrowth
of a series of experiments performed with the object of
determining the role played by the medulla oblongata
and pons varolii in the evolution of general convulsive
phenomena. In the course of these investigations
this observer ascertained that there is a limited spot
in the floor of the fourth ventricle, the irritation of
which (with a needle, etc.,) causes tonic and clonic
spasms of the entire system of voluntary muscles.
This spot has been appropriately designated by him
as the " convulsion center."

According to Nothnagel's theory, the convulsions
of the epileptic paroxysms are due to irritation of this
circumscribed locality.

But, while such irritation is sufficient to evoke the
spasms, it is not adequate to account for the uncon-
sciousness. Accordingly, to overcome this difficulty,
Nothnagel assumes a concomitant irritation of the
neighboring vaso-motor center. As a result of this
irritation the arteries of the brain, as well as those of
the rest of the body, are contracted, causing anaemia;
and it is to this cerebral anaemia that the unconscious-
ness is due. The co-ordinate excitation of the vaso-
motor and " convulsion centre " constitutes, then, ac-
cording to this theory, the essential pathological fea-
ture of the typical paroxysm.

* "Uber den epileptischen Anfall," von H, Nothnagel.
Volkmann's " Sammlung klinischer Vortrage," Leipzig, 1872.

— 151 —

But, while this is assumed to be the course of
events in typical cases, it does not serve to explain
the occurrence of variations in the character of the
seizure.

Accordingly, with a view to rendering the theory
as broad as possible, Nothnagel furthermore assumes
that the centres above referred to are in a certain
sense independent of each other, so that one may be
irritated without the other. Thus, when the "con-
vulsion center" is irritated alone, the paroxysm is
characterized by convulsions without unconsciousness;
whereas, when the " vaso-motor center " is excited
mental disturbances and loss of consciousness are the
prominent features.

This is certainly an ingenious method of avoid-
ing a logical dilemma; but, unfortunately, the extreme
contiguity of the two centres renders their indepen-
dent irritation exteremely improbable, since any mor-
bid changes affecting the one would be practically cer-
tain to involve the other.

CHAPTER XI.

CONCERNING THE NATURE OF THE IRRITATION

—THEORIES OF NOTHNAGEL. TODD

AND HUGHLINGS JACKSON.

With regard to the nature of the irritation which
calls forth the activity of the above-named centers,
Nothnagel confesses that little can be said with cer-
tainty.* He believes, however, that in epilepsy " the
convulsions do not depend upon an anaemia of the
pons, acting as an excitant upon the convulsion
centre;"f though admitting that anaemia of the pons
can occasion convulsions, as shown by certain of Kuss-
maul's experiments.

As to the second stage of the attack, Nothnagel
believes that the intense venous hyperaemia is attribut-
able to the violent contractions of the muscles of the
neck, which, pressing upon the large veins, impede
the return of the venous blood to the heart. The
continuance of unconsciousness, as well as the con-
vulsions, are to be ascribed to this venous hyperaemia,
one of the effects of which is to cause irritation of the
"convulsion center."

It now remains to consider briefly that theory of

*Von Ziemssen's "Cyclopaedia," article " Epilepsy," by
H. Nothnagel, vol. xiv; p. 269, seventeenth line from the top.
fOp. cit., p. 268.

— '53 —
epilepsy which ascribes the essential feature of the dis-
ease to a discharge or explosion of nerve force. Dr.
Robert B. Todd* was the first to regard the disease
from this point of view. It is impossible to read the
paper in which this gifted writer formulates his views
upon this, one of the most intricate chapters in pathol-
ogy, without experiencing a sense of admiration for
the perspicuity and logical adroitness displayed.

Dr. Todd considers that the abnormal explosive-
ness of nervous tissue, which is the principal factor in
his theory of epilepsy, is due to the gradual accumula-
tion of a morbid material in the blood. This foreign
substance finally becomes so abundant as to cause the
discharge of nerve force from the brain, by which the
phenomena of the fit are produced.

This theory of epilepsy was suggested to the
mind of Dr. Todd from the fact that the disease oc-
casionally occurs with renal affections. " Upon this
fact of the dependence of attacks of epilepsy upon
renal disease," he says, " I have been enabled to con-
struct a theory of the cause of epileptic fits generally."
Continuing the argument, he adds: " I hold that the
peculiar features of an epileptic seizure are due to the
gradual accumulation of morbid material in the blood,
until it reaches such an amount that it operates upon

*A Clinical Lecture on a Case of Renal Epilepsy, and on
the Treatment of Epilepsy in General," by Robert B. Todd,
M. D., Medical Times and Gazette, Aug. 5, 1854.

— 154 —
the brain in, as it were, an explosive manner; in other
words, the influence of this morbid matter, when in
sufficient quantity, excites a highly polarized state of
the brain, or of certain parts of it, and these discharge
their nervous power upon certain other parts of the
cerebro-spinal center in such a way as to give rise to
the phenomena of the fit. A very analogous effect is
that which results from the administration of strych-
nine, which is best seen in a cold-blooded animal like
the frog. You may administer this drug in very
minute quantities for some time without producing
any sensible effect; but, when the quantity has ac-
cumulated in the system up to a certain point,
then the smallest increase of dust will immediately
give rise to the peculiar convulsion phenomena. The
animal is thrown into a series of paroxysms of opistho-
tonos, which exactly imitate the phenomena which we
often witness in tetanus, as it affects man and some of
the higher animals."*

This, then, is Dr. Todd's conception of the causa-
tion of the paroxysm — the so-called humoral theory of
epilepsy.

The theory enunciated by Dr. Todd has been
modified and developed by Hughlings Jackson. f Ac-
cording to Dr. Jackson, epilepsy, " defined from the
paroxysm, is a sudden, excessive, and rapid discharge
of gray matter of some part of the brain; it is a local

*0p. et loc. cit.

f "West Riding Lunatic Asylum Medical Reports," 1873.

— 155 —
discharge. To define it from the functional altera-
tion, we say there is in a case of epilepsy gray matter
which is so abnormally nourished that it occasionally
reaches very high tension, and therefore occasionally
explodes. The two definitions are different faces of
the same thing."

The discharge, beginning at the cortex, is propa-
gated along the course of the centrifugal nerve chan-
nels. As to the loss of consciousness, Dr. Jackson
feels justified in ascribing it to the transitory exhaus-
tion of nervous energy, consequent upon the previous
inordinate discharge.

The fact that in a considerable number of epilep-
tics the paroxysm is ushered in by a psychical warning,
or an aura of special senses, has been urged as strong
evidence in favor of the proposition that the discharge
begins in the convolutions. And, in truth, it must be
acknowledged that it is difficult to conceive how a
primary functional implication of the medulla or pons
Varolii could evoke phenomena which, by common
consent, are conceded to be the expression of the ac-
tivity of the highest centres.

According to this theory, then, the protoplasm of
the ganglion cells is in an unstable, super-explosive
condition, attributable, perhaps, to excessive nutrition
(as the result of expanded blood-vessels, etc.). Jack-
son has not, however, remained content with explain-
ing the modus operandi of the ordinary epileptic par-
oxysm, but has also sought to render his theory sufifi-

- X56 -

ciently comprehensive to account for the evolution of
irregular forms of the attack. Accordingly, it is
assumed that in one class of cases certain portions of
the gray matter may be affected, while in a second
class of cases other portions may be involved. The
various modifications of the seizure are, therefore, ex-
plained by a consideration of the physiological pro-
perties of the group of nerve-cells involved in each
case.

While heartily indorsing the main features of this
theory, I cannot accept it in all its details, for the
very excellent reason that cerebral physiology is
not as yet sufficiently developed to admit of such
pathological refinements.

CHAPTER XII.

PROGNOSIS— TREATMENT.

From the very earliest periods of recorded history-
epilepsy has been regarded as a grave disease.
Doubts of its curability have been expressed, even at
the present day; this, however, according to such ex-
cellent authorities as Herpin and Nothnagel, is the
extreme of pessimism and is not sustained by clinical
experience.

When the disease begins early in life, say before
the eighteenth year, the prognosis, all things being
equal, is more favorable than when the disease comes
on late in life.

In those cases where the first attack is traceable
to a peripheral cause, the prospects of recovery, pro-
vided we succeed in removing such cause, is greater
than when we have to do with a gross central lesion.

Long intervals between the attacks are considered
of favorable import by some, but by others they are
believed to presage a doubtful recovery.

The character of the seizure has no great influ-
ence on the prospects of recovery; and in forming an
opinion on that question we may apply about the
same course of reasoning to a case of grand mal as to
one of minor epilepsy.

The principal methods of treating the disease in

- 158 -

vogue at the present day resolve themselves into
surgical procedures (medicinal) measures and dietetic
expedients.

By resort to surgery we remove an offending
cicatrix, the irritation emanating from which may
cause the explosive condition resulting in the seizures.
The same means also enable us to elevate a depression
in the skull, and to remove by the aid of the trephine
irritating substances from the surface of the meninges,
Happy results soon followed such applications of
surgery; but unfortunately the number of cases sus-
ceptible of such treatment is relatively small, so that
in the majority of cases we have to rely upon the in-
troduction of chemicals into the system, and upon
careful regulation of the diet to prevent or diminish
the frequency of the seizures.

The chemicals which have been employed as
medicines in the treatment of epilepsy aie legion.
Among those which, at one time or another, have en-
joyed a wide celebrity I would mention the following:
Valerian, wormwood, hyoscyamus, belladonna, oxide
of zinc, nitrate of silver, and in the form of inhalations,
chloroform, ether, and the nitrite of amyl. During the
last ten years the bromides have become the fashion-
able remedies in epilepsy. At one time great things
were expected from electricity, and while these expec-
tations have not been entirely realized, it must be con-
ceded that great benefits are occasionally witnessed
from the application of the constant galvanic current

— 159 —
about the head. I, myself, have frequently witnessed
diminution of the number of seizures subsequent to
prolonged applications of weak galvanic currents to the
head. The faradic current, on the contrary, is of no
particular use even in the treatment of epilepsy.

The first question which naturally suggests itself
to the physician in connection with the treatment of
epilepsy is: "What shall we do when the attack has
already begun ?" We answer, if the attack be of brief
duration, a masterly inactivity is the prime desider-
atum. But if, on the contrary, we have to do with the
status epilepticus, with one seizure following the other
in rapid succession, we should by all means abate the
attack. This may be attained in almost all cases by
applying firm pressure to the stems of both com-
mon carotid arteries with the fingers, or, better still,
with one of the instruments which I had constructed
several years since for the purpose.* The implement
in question consists, in the first place, of two curved
metallic branches, resembling in shape an inverted
horseshoe. At each of the extremities of the horn is
a small padded piece of metal, which may be set at an
angle by means of a key. The object of this arrange-

*" Prolonged Instrumental Compression of the Primi-
tive Carotid Artery as a Therapeutic Agent," by J. Leonard
Corning, M. D. The Medical Record, Feb. i8th, 1882. Also
"Carotid Compression." Ibid. Anson D. F. Randolph &
Co., New York, 1882.

— i6o —

ment is to permit of so arranging the pads that the
artery is pressed away from the jugular vein, in the
direction of the spinal column. The toe of the horse-
shoe is, furthermore, so secured to a handle by pivots
that by rotating a screw the arms of the horseshoe
may be opened or approximated at will.

When employing the instrument, the patient, if in
bed, or on the floor, is placed in a horizontal or semi-
dorsal position, with the head supported by a cushion
beneath the neck, in such a manner as to allow the
the cranium to fall slightly backward, thus causing a
protrusion of the cervical vertebrae, in an anterior
direction. The operator then takes his place at the
side of the patient, and proceeds to ascertain by care-
ful exploration the exact location of the carotids.
Having accompli.shed this, he next applies the instru-
ment in such wise that the pads will press the arteries
away from the pneumogastric nerves and jugular veins
in the direction of the spinal column. By pressing
one hand against the posterior portion of the neck, it
is possible to execute any amount of counter-pressure.
Compression should, however, never be carried to
such a degree as to cause entire closure of the lumina
of both arteries.

Besides the device just described, I have also had
made for me appliances, by the use of which it is pos-
sible to employ compression of the carotids for pro-
longed periods of time, with or without simultaneous

— i6i —

galvanization of the sympathetic and pneumogastric
nerves."^

Not only is it possible to arrest the succession of
paroxyms peculiar to the status epilepticus in the man-
ner above described, but it is also sometimes possible
to prevent the occurrence of seizures for weeks to-
gether, by maintaining continuous compression of the
carotids, f

As an adjunct to the treatment, then, carotid-
compression, by the aid of appropriate appliances is a
most valuable expedient, especially when combined
with the administration of the bromides.

' Of these last mentioned remedies it is now neces-
sary to speak. During the last ten or fifteen years
the bromides, and especially the bromide of potassium,
have been more employed in epilepsy than any other
remedies heretofore recommended. In order to pro-
duce the best results, it should be given in doses vary-
ing from fifteen to forty-five or even fifty grains. Very
young children are, however, sometimes benefited by
small doses of from six to ten grains. While the
potassium salt is preferred by some neurologists, the
sodium salt has been praised by others. For my own

* For a further description, as well as for illustrations
showing these appliances, see the New York Medical Journal
for February 23,1884. Also "Brain Rest," by J. Leonard
Corning, M. D. Second edition. G. P. Putnam's Sons, New
York, 1885.

f The " Medical Record," February 18, 1882.

l62

part, I must confess that I prefer a mixture of these
two salts, or still better a solution containing the
amonium, the potassium, the sodium and the lithium
salts. The following is a simple formula :

IJ Bromide potassii.

Bromide amonii.

Bromide lithii,

Bromide sodii, aa Z ij-

Aquae, 3 vj.
M.
Dose, from one to four teaspoonsful three times a day.

By the concurrent administration of arsenic the
troublesome eruption of acne, which frequently follows
the exhibition of the bromides, may sometimes be pre-
vented. The rash having, however, made its appear-
ance, it is well to cut down the dose of the bromides
at once, or even to discontinue their administration
for a time altogether. During the interim the oxide
of zinc may be given in doses of from one to five
grains. In this way it is often possible to prevent the
recurrence of the attacks, which may easily happen, if
the patient is deprived of all medicine for some days.

Where there is a suspicion of syphilis the iodide
of potassium should be, of course, at once resorted to.
To obtain the best results it should be given in large
doses.

CHAPTER XIII.

TREATMENT CONTINUED— EPILEPTIC
INSOMNIA.

As disorders of sleep constitute an important
feature of almost all forms of functional nervous de-
rangement, it is important to possess some knowledge
of this complication, inasmuch as without such knowl-
edge the physician speedily finds that his efforts at
amelioration are at once annoying to the patient and
barren of results. Before taking up the treatment of
that distressing and destructive form of sleeplessness
which is such a frequent accompaniment of epilepsy,
I desire to say a word or two regarding sleeplessness
in general: To begin, then, insomnia may be classi-
fied into two principal divisions, primary or idiopathic
insomnia and secondary or symptomatic insomnia.
By primary insomnia we understand that form of
sleeplessness which is directly traceable to some dis-
turbances of the brain itself. This is the variety of
insomnia with which we are most frequently con-
cerned in the treatment of epilepsy.

When we speak of secondary insomnia we mean
that form of sleeplessness which may be traced to
some corporeal disturbance external to the brain itself,
but which, acting on the cerebral mechanism through
the agency of the centripetal nerves gives rise to a

— 164 —

degree of irritation sufficient to prevent the superven-
tion of unconsciousness. The symptoms of both the
idiopathic and symptomatic varieties of the affection
resemble each other closely, so that a general de-
scription is all that is needed.

A person afflicted with insomnia, but otherwise
exempt from serious nervous difficulty, complains
either that he cannot fall asleep, or that, although he
may succeed in maintaining unconsciousness through-
out the night his sleep " does him no good," as he is
in the habit of expressing it. The first phase of the
affection, characterized by difficulty in falling asleep,
is familiar to persons who are laboring under great
emotional or mental strain, and who carry their busi-
ness or worry to bed with them. Difficulty of main
taining the condition of unconsciousness, that state in
which the patient awakes soon after falling asleep or
during the early morning hours, — is frequently en-
countered among those who are addicted to abuses of
the table; while the ability to sleep through the night,
and yet to experience scant refreshment from such
protracted slumber, represents a pathological condi-
tion peculiar to those who are the victims of uncon-
scious cerebration or dreaming or both. Those who
are victims of this morbid cerebral condition simply
carry on their mental efforts unconsciously, but
though laboring thus, all unbeknown to themselves,
the consumption of cerebral energy goes on apace, so
that there is little or no repose whatever.

- i65 -

Persons who are the victims of this derangement
suffer immensely, not the least of their troubles con-
sisting in their total inability to account for the feel-
ings of lassitude which assail them immediately on
rising from what they imagine to be a perfect type of
sleep.

Besides dreaming and unconscious cerebration,
derangements of the liver and kidneys sometimes pro-
duce this morning lassitude, and the same may be
said of that exhaustion which supervenes npon pro-
tracted mental labor, worry, or both combined.

In epileptics, and more especially in those who
have become inmates of asylumns in consequence of
mental trouble, we encounter an interesting phase of
insomnia, which, for most practical reasons is worthy
of study.

This variety of insomnia comes on in the first
place as the sequence of an attack: the patient awakes
from the comatose condition incident to the attack;
he is drowsy and may sleep for a considerable length
of time, but the same night he is restless and may fail
to procure even an hour of sleep, and on the follow-
ing morning gives unmistakable evidence of having
suffered severely from the involuntary vigil.

Sometimes, again, the attack of insomnia comes
on with no other warning than an unusual degree of
restlessness or irritability. The effects of these en-
forced vigils in persons afflicted by such a grave dis-
ease as epilepsy are often of a most disastrous char-
acter.

— i66 —

Sometimes the attack of insomnia is followed by
a terrible outburst of maniacal furor, while in a cer-
tain number of cases there is a well-marked increase
in the number of convulsive seizures. Again, in a
milder class of cases, the general health of the patient
undergoes rapid deterioration; he becomes irritable
and subject to attacks of depression; his complexion
becomes sallow; his face assumes a stupid, emotion-
less expression; he loses flesh, and, in short, falls into
a rapid decline, with but one prospect, that of speedy
dissolution.

The more I have seen of epilepsy the more have
I become convinced of the necessity of treating sys-
tematically and promptly this epileptic variety of in-
somnia. Fortunately, the problem involved is not so
difficult as it might appear at first sight. In the first
place the patient should be continuously saturated
with the bromides, but not bromized. He should be
given from thirty to seventy-five grains a day, each
dose to be combined with one or two minims of the
liquor arsenicalis. Given in this way the bromides
many be continued for many years, if need be. In
severe cases it may be necessary to increase the dose
still further, as we have already seen; but, in a con-
siderable percentage of cases, this dosage will be found
sufficient to prevent the attacks, and at the same time
to exert a progressively tranquilizing influence upon
the cerebrum as night approaches. At bed-time, or
shortly before it, twenty or thirty grains of chloral

— 167 —

may be given, combined either with two or three
drachms of the tincture of hyoscyamus, or with a
drachm of the bromide of potassium.

Several years ago, when I published the first
edition of my little book on " Brain Rest," I advocated
the seclusion of patients afflicted with insomnia, or for
whom prolonged sleep had been prescribed as a fea-
ture of treatment, in a darkened room. I can only
repeat on this occasion what I then said :

The subject is secluded in a darkened room from
ten to fifteen hours at a time, according to the amount
of sleep which it is desired shall be had during the
twenty-four hours. The amount of sleep is progres-
sively increased by habit, moderate medication, and
hydrotherapy, and no attempt is made to produce a
sudden state of stupor by the reckless use of sedatives.
When the patient awakes, as is usually the case, two
or even three times during the hours set apart for rest,
nourishment is administered, but always in a fluid and
easily digested form. Where difficulty is experienced
in again falling asleep, resort is had in the beginning
to limited medication. The few hours of wakefulness
are devoted exclusively to some form of amusement
— reading, writing, and even the mildest forms of
mental concentration being absolutely prohibited.
This, in brief, is the method from which I have already
seen most happy results, and from the employment of
which I hope and believe much good will in future be
derived. It is hardly necessary to say that the prob-

— i68 —

lem of cerebral rest is essentially different and pre-
sents many more difficulties than spinal rest. To
give repose to the motor cells of the cord is compara-
tively an easy problem, and one which only exacts a
permanent fixation of the motor apparatus for its solu-
tion, the consciousness or unconsciousness of the in-
dividual being only a matter of secondary importance.
Rest, however, for those cells, the function of which
is the evolution of mind, can only be obtained by a
prolonged period of absolute unconsciousness; and
this, as a matter of course, will often tax the patience
and resources of the physician to the utmost. Perse-
verence and the utilization of the principle of habit
will usually, however, render essential assistance.

These are the views which I expressed in 1883,*
when discussing the most rational method of treating
cerebral exhaustion. All that I then said may be
properly applied to the treatment of a large number
of functional nervous affections, and particularly in
the treatment of chorea and epilepsy. So manifestly
important is the question of sleep in the treatment of
the latter aft'ections, that I trust I have not trespassed
too much upon the patience of the reader, by discuss-
ing the matter somewhat at length. It has been a
matter of great surprise to me that so little attention
should heretofore have been bestowed upon this im-
portant matter of prolonged sleep in the treatment of

* The New York Medical Journal for December 29, 1883.

— 169 —

convulsive nervous affections. From quite an exten-
sive personal experience both in insane asylum and
private practice, I am convinced that the subject is
one of superlative importance, when it is a question of
restoring derangements of cerebral nutrition, whether
such be the concomitants of exhaustive or convulsive
conditions.

INDEX-

A. Page. ,

Amaurosis in Hysteria 39

Amblyopia in Hysteria 39

Anaesthesia in Hysteria 37

Ansethetics 12

Hysterical Manifestation Following the Admin-
istration of Anaesthetics Generally Occur
in Neurotic, Hysterically Inclined Individ-
uals 16

Hysterical Phenomena Consequent Upon the

Administration of 12

Lyman's Cases Illustrating False Beliefs of
Women Engendered by the Administration

of 13

Aurae Epileptical 85

Auditory 87

Motor 88

Olfactory 88

Psychical 89

Secretory 87

Sensory 85

Taste 88

Vaso-motor 86

Visceral 88

Visual 87

c.

Carotids, Compression of in Epilepsy, Coming's Method

of Executing 159 ^^ J^/-

Cerebral Rest, Coming's System of Affording 167

Contractures in Hysteria 45

— 172 —

Page.

" Convulsion Center " 131

Convulsions 118

Blood-letting as a Cause of; Pioray on, Kellie
on, Marshall Hall on, Sir Astley Cooper

on iij et seq.

Brown-Sequard on 133

Challand on 136

Landois on the Relation of Venous Hyperae-

mia to 129

Magnan on 136

Nothnagel's Researches on 131

Kussmaul and Tenner on the Physiology of,

120 et seq.
Westphal on 135

E.

Epilepsy 83

Age in in

Alcohol in in

Aathor's Statistics on the Relative Frequency of

in Men and Women in

Bromides in 161

Brown-Sequard on 133

Carotid-Compression in. Coming's Researches

Regarding 159

Causation of IC9

Classification of 83

Cooper, Sir Astley, Researches of, on 118

Cranial Injury in 114

Excesses in 112

Experimental Researches on 117

Fever in 113

Gower's Statistics in in

Heredity in no

— 173 —

Page.

Epilepsy Hippocrates' Views Regarding 117

Insomnia of 163

Iodide of Potassium in 162

Irregular forms of (Masked Epilepsy) 99

*' Jacksonian " 104

Kellie on 117

Kussmaul and Tenner on 120 et seq .

Landois on 129

Major Variety of 90

Marshall Hall on 118

Minor Variety of 95

Nothnagel on 131

Patho-anatomical Findings in 139 ^^ seq.

Pioray on 117

Prognosis of 157

Prolonged Sleep in 167

Sensory 107

Sex in tii

Symptoms of 84

Thalamic 103

Transition forms of 97

Treatment of 158 et seq.

Westphal on 135

Zinc in 162

Epileptic Seizure, Mechanism of 142

Hughlings Jackson on 154

Kussmaul and Tenner on 143

Marshall Hall on 143

Nothnagel on 150

Todd on, " Humoral " Theory of 153

" Epileptogenous Zone" 134

G.

Globus Hystericus, Galvanism in 81

Grand Mai 90

— 174 —

H.

Hyperaesthesia in Hysteria 25

Hysteria 1

Case from Author's Experience Illustrating Mor-
bid Impulse to Commit Violence 19

Causation of 68

Clauston's Observations on Hysterical Insanity. . 21

Contractures in 46

Cough, Peculiar in 50

Craving for Sympathy in 6

Crimes in 7

Deception in 6

Definition of i

Diagnosis of 72

Hearing, Exaltation of in 28

HyperEesthesia in 25

in Children 62

in Men 67

Insanity as a Complication of 21

Insanity in Case of Clauston Illustrating 23

Medico-Legal Relations of, Importance of 20

Morbid Impulses to Commit Acts of Violence in, 18
Motive for Violent Acts in not Always Ascertain-
able 20

Motor Disorders in 41

Mutilation in 8

Notoriety or Desire for Sympathy as a Cause of

Violent Acts in ig

Ovarian Troubles as a Cause of 3

Ovaries, Hyperaesthesia of in 30

Pain, Morbid Sensibility to in 29

Paralysis in 44

Paroxysmal Attacks in 57

Pathology of 70

— 175 —

Page.

Hysteria, Prognosis of 74

Psychical Manifestations of . . . 5

Retention in 8i

Sensory Disorders in 25

Sight Exaltation of in. . .* 27

Smell, Exaltation of Sense of in 26

Spasms in 41

Taste, Exaltation of in. . . . 27

Treatment of 75

Tremor in 47

Vaginismus in, Scanzoni on, Thomas on 43

Vaso-motor Disorders in . . 49

Hysterical Attack, The 57

Hysterical Cough 50

Author's Cases of 54

Hartley's Remarkable Cases of 51

Synclair's " Acute " Case of 56

Hystero-epilepsy 58

I.

Insomnia of Epilepsy 163

Disastrous Effects of 165

J.

" Jacksonian " Epilepsy 104

Joints, Painful, in Hysteria 33

Brodie, Sir Benjamin on 32

Skey on Pain in Joints in Hysteria 34

L.

Larvated Epilepsy 99

M.

Medico-Legal Relations of Hysteria 20

— 176 —

Page.
O.

Ophthalmoscopic Appearances, Absence of Characteristic

in Hysteria 39

Ovaries, Hyperaesthesia of, in Hysteria 30

P.

Pain in Hysteria 29

Dorsal, in Hysteria 31

Morbid Sensitiveness to, in Hysteria 29

Ovarian, in Hysteria 30

Paralysis in Hysteria 44

Petit Mai 95

S.

Sensory Disorders of Hysteria 25

" Sensory Epilepsy " 107

Sir Benjamin Brodie on Painful Joints in Hysteria 32

Spasms in Hysteria 41

Suicide, Fictitious Attempts at on the Part of Hysterical

Persons 16

Case Illustrating Fictitious Attempt at Self-de-
struction from the Author's Experience 17

T.

' ' Thalamic " Epilepsy 103

Tremor in Hysteria 47

V.

Vaginismus in Hysteria, Thomas and Scanzoni on 43

Violence, Morbid Impulse to Commit Acts of Among the

Hysterical 18

Visual Disturbances in Hysteria 39

ANODYNES AND HYPNOTICS.

Necessity for Absolutely Uniform Preparations.

Pain is the most marked indication of disease. To assuaging it the physician's
first and best efforts are directed, and to the patient its relief is the tangible evi-
dence of the Doctor's skill. It is not strange, therefore, that anodynes and
hypnotics play so important a part in the medicinal resources of every physician.

The ideal anodyne and hypnotic free from reaction or disagreeable after-
effects remains to be discovered. Those most frequently resorted to are the prep-
arations of opium, the bromides and chloral . When the toxic properties of these
remedies and their vast consumption is considered, the necessity for the employ-
ment of absolutely uniform and pure preparations of them is evident.

We beUeve in standardizing toxic drugs, and supply a line of standardized fluid
extracts of such drugs as ergot, aconite, belladonna, cannabis indica, gelsemium,
foxglove, nux vomica and others, and believe they will commend themselves to all
scientific physicians.

In cases in which opium is contra-indicated many physicians use with satisfac-
tion fluid extract Jamaica dogwood (Piscidia erythrina), which is both an anodyne
and hypnotic, relieving pain and securing quiet, refreshing sleep, and which is free
from the distressing after-effects of opium preparations.

There are certain proprietary preparations of anodynes largely prescribed by
physicians for which, at the solicitation of many members of the profession, we
have prepared scientific substitutes which are, we believe, equally efHcient and
may be ethically prescribed. Thus we have prepared chloranodyne as an improve-
ment upon the well-known proprietary preparation chloranodyne. It is a happy
combination of well known sedatives, anodynes and anti-spasmodics, and is deserv-
edly popular. It is especially serviceable in acute intestinal inflammations, as
colic, dysentery and in dyspepsia, neuralgia, toothache, etc.

Cerebral sedative compound is a valuable hypnotic which we offer as a scienti-
fic substitute for bromidia. We prepare two formulae of it: one contains potassium
bromide, chloral hydrate, gelsemium and opium. In the second, henbane is sub-
stituted for the opium.

We have also a line of pills and hypodermic tablets of anodynes, sedatives and
hypnotics.

Descriptive circulars, giving formulae and all desired information regarding our
standardized products and improved pharmaceutical preparations furnished on
request.

' PAEKE, DAVIS & CO.,

Manufacturing Chemists,

NEW YORK:
Offices, 60
Warehous
Crude Drug Warehouse, 218 Pearl St

Offices, 60 Maiden Lane. DFTROTT WXCmdAM

Warehouse and Shipping Depot, 21 Liberty St L»C. I KUl 1 , lYllCHH:rAW.

%\-}c l^liDsici^D-s' |Ccisi|i'c |^ibJ>i)l-i),

PRICE : PAPER, 25 CTS. PER COPY, $2.50 PER SET ; CLOTH, 50 CTS, PER COPY,
$5,00 PER SET.

SERIES I.

Inhalers, Inhalations and Inhalants.
By Beverley Robinson, M. D.

The Use of Electricity in the Removal of
Superfluous Hair and the Treatment of
Various Facial Blemishes. _
By Geo. Henry Fox, M. D.

New Medications. ,, ,^

By Dujardin-Beaumetz, M. D.

The Modern Treatment of Ear Diseases.
By Samuel Sexion, M. D.

Spinal Irritation. ^, , ., r^

By William A. Hammond, M. D.

The Modern Treatment of Eczema.
By Henry G. Piffard, M. D.

Antiseptic Midwifery.

By Henry J. Garrigues, M. D.

On the Determination of the Necessity for
Wearing Glasses. _

By L). B. 6t. John Roosa, M. D.

The Physiological, Pathological and Ther-
apeutic Effects of Compressed Air.
By Andrew H . Smith, M. D.

GranularLids and ContagiousOPhthalmiai
By W. F. Mittendorf, M. D.

Practical Bacteriology.

By Thomas E. Satterthwaile, M. D.

Pregnancy, Parturition and the Puerperal
State and their Complications-
By Paul F. Mund^, M. D.

SERIES II.

The Diagnosisand Treatment of Haemor-
rhoids. ,, , ., ^
By Chas. B. Kelsey, M. D.

Diseasesof the Heart. Vol.1.

By Dujardin-Beaumetz, M. D.

Diseasesof the Heart. Vol. (I.

By Dujardin-Beaumetz, M D.

The Modern Treatment of Diarrhoea and
Dysentery. ,, ^

By A. B Palmer, M. D.

Intestinal Diseases of Children.
By A. Jacobi, M. D.

The Modern Treatment of Headaches. ^
By Allan McLane Hamilton, M. D.
The Modern Tieatment of Pleurisy and
Pneumonia.

By G. M. Garland, M. D.

How to Use the Laryngoscope.

By an Eminent Laryngologist.

Diseases of the Male Urethra.

By Kessenden N. Otis, M. D.
The Disorders of Menstruation. _

By Edward W. Jenks, M. D.
The Infectious Diseases. In 2 vols.

By Karl Liebermeister.

SERIES III.

Abdominal Surgery.

By Hal C. Wyman, M. D. Ready.

Diseasesof the Liver. ,, „ „ .

By Dujardin-Beaumetz, M.D. Ready.

Hysteria and Epilepsy. . ,^ „ .
By J. Leonard Corningr, M. D. Aug.

Diseases of the Kidney. ,, r. c
By Dujardin-Beaumetz, M. D. Sept.

The Theory and Practice of the Ophthal-
moscope.

By J. Herbert Claiborne, Jr., M. D.
September.
Modern Treatment of Bright's Disease.
By Alfred L. Loomis, M. D.
October.

j Clinical Lectures on Certain Diseases Of
I Nervous System.

By Prof. J. M. Charcot, M. D.
October.
The Radical Cure of Hernia.

Bv Henry O. Marcy, A. M., M. D.,
I.. L D November.

The Treatment of Diseases of the Blad-
der, Prostate and Urethra.

By H. O. Walker, M. D. Nov.

Dvspepsia. _ ,

Hy Frank Woodbury, M. D. Jan. '89.

The Treatment of the Morphia Habit.
By Erlenmeyer. December.
Transla-ed by J. B. Mattison, M.D.

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